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COPYRIGHT DKHOSIT. 




Miliary Choroido-retinitis. 

(See Page 344.) 



PREVALENT DISEASES 
OF THE EYE 



A REFERENCE HANDBOOK, ESPECIALLY 
ADAPTED TO THE NEEDS OF THE GENERAL 
PRACTITIONER AND THE MEDICAL STUDENT 



BY 

SAMUEL THEOBALD, M.D. 

Clinical Professor of Ophthalmology and Otology in the Johns Hopkins University 

Ophthalmic and Aural Surgeon to the Johns Hopkins Hospital, and to the 

Baltimore Eye, Ear, and Throat Charity Hospital ; Consulting Ophthalmic 

and Aural Surgeon to the Home for Incurables, and to the 

South Baltimore Eye, Ear, and Throat Charity Hospital. 



WITH 219 ILLUSTRATIONS 
AND IO COLORED PLATES 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1906 



. T3 



[LIBRARY of CONGRESS 
Two Conies Received 

AUG 14 1906 

/\ Cownfeltt Entry 
$ASS7 O. XXc. No 

7 /SZO/G 

COPY B. 



Copyright, 1906, by W. B. Saunders Company 



PRESS OF 
B. 6AUNDERS COMPANY 
PHILADELPHIA 



PREFACE. 



Although most treatises upon diseases of the eye 
have been written ostensibly for the general practitioner 
and the medical student, they have been, with few ex- 
ceptions, adapted in reality not to their needs, but to 
the requirements of the specialist in this department of 
medicine. A treatise upon the eye really intended to 
meet the needs of the general practitioner, it has seemed 
to the author, should take into account the fact that the 
great majority of physicians are not skilled in the use of 
the ophthalmoscope, and are not likely ever to be; that 
they possess neither the experience nor the necessary 
paraphernalia to make trustworthy tests of refractive 
errors, of muscular anomalies, or of the visual fields; 
and that they are not qualified to perform, and have no 
desire to undertake, the more delicate eye operations. 
It should recognize, further, that because of these limita- 
tions the general practitioner is hopelessly handicapped 
as regards the diagnosis, and consequently the treat- 
ment, of many important eye affections; but, on the 
other hand, that there are other important affections 
of the eye which he is competent, or should be com- 
petent, to diagnosticate correctly, and to treat success- 
fully. 

It should, therefore, devote especial attention to this 
latter class of maladies, and, particularly, should help 
him to discriminate between these cases and those 



PREFACE 



which are without his province, so that, on the one hand, 
he may not send trivial affections, which he is himself 
competent to treat, to the distant specialist, or, on the 
other hand, lose precious time, and thus permit sight 
to become irreparably damaged, through attempting to 
cope with maladies which urgently demand the skill 
of the trained ophthalmologist. 

Again, such a work should take into account that the 
general practitioner is most in need of definite infor- 
mation as to the more frequently encountered diseases 
of the eye, and, while these should be dwelt upon, that 
it is a work of supererogation, so far as he is concerned, to 
give space to the description of rare affections which, in 
all probability, he will never encounter. It should also 
make clear to him the sharp line to be drawn between 
those diseases of the eye in which delay in the employ- 
ment of remedial measures is permissible, or even desir- 
able, and those in the treatment of which time is an all- 
important factor. 

In offering suggestions as to treatment, it should be 
concise, unambiguous, and as specific as practicable, 
not giving a long list of remedies, and leaving the inex- 
perienced reader to choose from among them, but 
recommending definitely what the author — if he is 
qualified to write such a book — should know, from his 
own observation, is best adapted to the condition under 
consideration. The simpler operations, which the 
general practitioner may perform, it should describe in 
detail; the more difficult ones, which he is not warranted 
in undertaking, need not be so described, though the 
indications for them should be clearly set forth. 

For such a book — not a complete treatise upon dis- 
eases of the eye, but a concise description of the com- 
moner ocular maladies — designed solely to meet the 



PREFACE. Ill 

needs of the physician engaged in general practice, the 
author is convinced there is a real want; and this want, 
with what measure of success it remains to be seen, he 
has endeavored to supply. 

Having in mind the well-worn proverb, "a little 
knowledge is a dangerous thing," he has not thought 
it desirable to encourage the general practitioner to rely 
upon the ophthalmoscope as a means of diagnosis. In- 
deed, he has not even given a description of it, or ex- 
plained its use. Furthermore, he has constantly as- 
sumed that the knowledge which it affords is not at 
the reader's command. For the same reason, he has 
not given a detailed account of the several methods of 
measuring the refractive and muscular anomalies of the 
eyes, of charting the visual fields, etc. On the other 
hand, especial pains have been taken to describe fully 
such aids to diagnosis (the examination by oblique il- 
lumination, for example) as can but prove helpful, and 
such therapeutic measures, operative and non-operative, 
as the general practitioner may employ with advantage. 
The hope is indulged that the introductory chapters 
upon "Diagnosis" and upon "Treatment" will prove 
of practical value. 

For greatly appreciated advice and many helpful sug- 
gestions in connection with the preparation and publi- 
cation of this work, the author takes pleasure in ac- 
knowledging his indebtedness to Dr. Wm. H. Welch and 
to Dr. Henry M. Hurd. He is also indebted to Dr. 
Albert H. Buck, editor of the "Reference Handbook 
of the Medical Sciences," for permission kindly accorded 
him to make free use, in writing Chapters V and VII, of 
the articles upon "Affections of the Conjunctiva" and 
upon "Iritis," which it was the author's privilege to 
contribute to that standard work. 



IV PREFACE. 

To Dr. A. Maitland Ramsay he is under obligation 
for permission to use several admirable illustrations 
from his "Atlas of External Diseases of the Eye." 

304 West Monument Street, 
Baltimore, July, 1906. 



SYNOPSIS OF CONTENTS. 



CHAPTER I. 



General Observations upon the Diagnosis of Diseases of the 
Eye. Description of the Methods of Examining the Eye 

Available to the General Practitioner _ 1 7-37 

The difficulties in diagnosticating diseases of the eye with which 
the general practitioner has to contend, 17. Some of the errors 
into which he is apt to fall, 17. His skill in the use of the oph- 
thalmoscope rarely such as to make it a trustworthy means of di- 
agnosis, 19. Other methods of examining the eye, 19. Oblique 
illumination, 19. Value of the information which it affords, 21. 
Facility in its employment easily acquired, 2 1 . The assistance 
afforded by a transitory mydriatic, 21. Eversion of the eyelids, 22. 
Determination of intra-ocular tension, 23. The reactions of the 
pupil, 24. Variations in the size and reactions of the pupil in 
health and disease, 25. Determination of visual acuteness, 27. 
Simple method of measuring the visual field, 29. The patient's 
description of his symptoms often misleading, 31. Pertinent 
questions which he should be asked, 31. Significance of his re- 
plies, 31. Inspection of the eye by daylight, 34. The condition 
of the lids, lacrimal apparatus, conjunctiva, cornea, anterior 
chamber, iris, the appearance and behavior of the pupil, the ten- 
sion of the globe, and the movements of the eyes, to be noted, 34. 
Loss of sensibility of the cornea — how determined, 35. Diag- 
nostic significance of the different types of vascular injection of 
the eye, and of the character and amount of the discharge pres- 
ent, 35. Examination of the anterior structures of the eye by 
oblique illumination, with and without the application of a 
mydriatic, 36. 

CHAPTER II. 

General Observations upon the Treatment of Diseases of 

the Eye 38-62 

A correct diagnosis having been reached the selection of the pro- 
per remedy to meet the condition usually not difficult, 38. Im- 
portance of constitutional remedies in the treatment of diseases 
of the eye, 38. The local and constitutional remedies especially 
useful in the treatment of eye diseases, 39. Indications for, and 
contraindications to, their use, and the methods of employing 



I a SYNOPSIS OF CONTENTS. 

PAGE. 

them, 39, 40. Importance of an early diagnosis, and the prompt 
employment of therapeutic measures, in many affections of the 
eye, 40. Transference of infectious material through the care- 
less use of eye-droppers, 41. Cautions necessary in the employ- 
ment of poisonous colly ria, 43. Colly ria as commonly prepared 
by the apothecary often contaminated, 43. Methods of apply- 
ing collyria and ointments to the eye, 44. Mydriatics, 46. Atro- 
pin, the most valuable local remedy in the treatment of diseases 
of the eye, capable of doing much harm when injudiciously em- 
ployed, 46. Possibility of its inducing glaucoma in persons 
beyond middle life, 47. Follicular conjunctivitis caused by its 
long-continued use, 48. Idiosyncrasies met with in individuals 
with reference to atropin and other mydriatics, 48. Myotics, 48. 
Indications for their employment, 48. Their mode of action in 
glaucoma, 48. Eserin the most valuable, 49. How it should 
be employed, 49. Contraindications to its use, 50. Astringent 
and antiseptic agents, 50. Useful especially in conjunctival 
affections, 50. Value of silver nitrate, protargol, and argyrol 
in the severer types of conjunctivitis, 51. The application of 
■carbolic acid and tincture of iodin to corneal ulcers, 5 r . Cocain 
useful only as an anesthetic, 5 1 . Harmful when otherwise em- 
ployed, 52. Causes desquamation of the corneal epithelium, 
and favors bacterial invasion, 52. Dionin a valuable analgesic 
and lymphagogue,52. Opium a valuable local remedy in ocu- 
lar inflammations, 53. Method of employing it, 53. Ointments, 
their preparation and uses, 53. Castor-oil in burns of the eye 
and abrasions of the cornea, 54. Light not the reprehensible 
thing it was formerly supposed to be, 54. The application of 
heavy bandages to the eyes, designed to exclude it, and con- 
finement in very dark rooms detrimental rather than helpful, 54. 
Inflamed and painful eyes, nevertheless, should be protected 
from undue exposure to light, 54. Method of examining and 
making applications to the eyes of children, 57. Constitutional 
remedies useful in the treatment of diseases of the eye, 57. The 
value, and indications for the employment, of mercury, potas- 
sium iodid, quinin, iron, strychnin, arsenic, sodium pyrophos- 
phate, pilocarpin, etc., in diseases of the eye, 57-61. Efficacy of 
the antitoxin treatment in diphtheritic conjunctivitis, 61. 



CHAPTER III. 
Diseases of the Eyelids and Orbit 63-117 

Diseases of the Eyelids. 

Blepharitis marginalis, 63. Commonly a chronic condition, 63. 
In children, eczematous in character, and usually due to malnu- 
trition and disturbed digestion; in adults, to accommodative 



SYNOPSIS OF CONTENTS. I b 



PAGE. 



strain, 64. Treatment, 65 Hordeolum, 67. Etiology and treat- 
ment, 69. Eczema, 71. Constitutional and local causes, 71. 
General and local treatment, 71. Chalazion, 73. Etiology, 74. 
Often multiple, 74. Chronic blepharitis a predisposing cause, 
74. Treatment, 74. Non-operative treatment seldom of avail, 
74. Description of operation found most effectual and easiest of 
performance, 75. Milium, 77. Hydrocystoma, 78. Warts, 78. 
Malignant growths, 78. Tarsitis, 79. Commonly of syphilitic 
origin, 79. Entropion, 80. Spasmodic entropion, 81. May 
result from spasm of the orbicularis, commonly dependent upon 
photophobia, or from senile relaxation of the lid-structures, 81. 
Faulty construction of the tarsal cartilage or of the arrangement 
of the orbicularis a predisposing cause, 81. Organic entropion, 
81. Produced by contraction of scar-tissue in or beneath the 
palpebral conjunctiva, 81. Usually consequent upon trachoma, 
8r. Treatment of spasmodic and organic entropion, 81. Opera- 
tive procedures indicated, 82. Correction of entropion of the 
lower lid by the production of an eschar with caustic potash, 82. 
Ectropion, 88. Like entropion, may be caused by spasm of the 
orbicularis, by contraction of scar tissue, or by senile relaxation 
of the lid-structures, 88. Spasmodic ectropion, 88. Etiology, 88. 
Organic ectropion, 89. May result from any lesion which leads 
to destruction of the external integument of the lid or neighbor- 
ing parts, 89. Incomplete ectropion of the lower lid a not infre- 
quent complication of disease of the lacrimal apparatus, 89. 
Non-operative and operative treatment of the different varieties 
of ectropion, 91. Snellen's operation for ectropion, 92. Value 
of Wolfe and Thiersch grafts in operations for the correction of 
ectropion, 97. Ptosis, 98. Occurs as a congenital and as an 
acquired fault, 98. Acquired ptosis, 98. Commonly due to 
paralysis of the third nerve, 98. Generally unilateral and of 
syphilitic origin, 98. Congenital ptosis, 98. Usually bilateral 
and caused by faulty innervation, or imperfect development or 
absence, of the levator muscle, 98. Treatment, 99. Only opera- 
tive treatment of avail in congenital ptosis, 99. In acquired 
ptosis operative measures indicated only after other means have 
proved ineffectual, 99. Gruening's modification of Bowman's 
operation for ptosis, 102. Panas' operation, 104. Paralysis of 
the facial nerve, 105. Symptoms and consequences, 105. Eti- 
ology. 106. Treatment, 106. 

Diseases of the Orbit. 

Cellulitis of the orbit, 108. Acute and chronic forms of the affec- 
tion, 108. Symptoms, 108. Etiology, 108. Fatal consequences 
from cerebral implication, 109. Treatment, 109. Periostitis, 
caries, and necrosis of the orbital -walls, in. Causes and conse- 



SYNOPSIS OF CONTENTS. 



PAGE. 

quences, in. Treatment, 112. Value of hydrochloric acid, 

113. Tumors of the orbit, 113. Mode of origin, 113. 

Varieties, 114. Consequences, 114. Diagnosis, 115. Treat- 
ment, 116. 



CHAPTER IV. 
Diseases of the Lacrimal Apparatus __ 1 18-150 

Diseases of the Lacrimal Gland. 

Of infrequent occurrence, because of the protected position of 
the gland and its multiple system of ducts, 118. Dacryoade- 
nitis, 119. Occurs as an acute and as a chronic affection, 118. 
Possible relationship to mumps, 119. Acute dacryoadenitis, 
119. Chronic dacryoadenitis, 119. Treatment, 120. Fistula 
of the lacrimal gland, 120. Dacryops, 121. Dacryoliths, 122. 
Dislocation of the lacrimal gland, 122. Met with as a sponta- 
neous condition and as a consequence of trauma, 122. Hyper- 
trophy of the lacrimal gland, 123. Atrophy of the lacrimal gland, 
124. Tumors of the lacrimal gland, 125. Are rare, and not infre- 



Diseases of the Drainage Apparatus. 

Of common occurrence, 125. Intimate pathological relation- 
ship between the drainage apparatus and the nasal passages, 
125. Atresia of the lacrimal puncta, 126. Occurs as a congeni- 
tal and as an acquired condition, 126. Treatment, 127. Mal- 
position of the puncta, 128. Eversion of the puncta, 128. In- 
version of the puncta, 128. Etiology and treatment, 128. Di- 
vision of the canaliculus the efficient remedy, 128. Description 
of the operation, 128. Atresia of the canaliculi, 130. Dacryo- 
liths, 131. Polypi, 131. Dacryocystitis, 131. Etiology, 131. 
Primary inflammation of the lacrimal sac, 131. Blennorrhea of 
the lacrimal sac, 132. Symptoms, 132. Mucocele, 132. Course 
of the disease, 132. Acute dacryocystitis, 133. Lacrimal fis- 
tula an occasional consequence, 134. Dacryocystitis rarely 
dependent upon ocular disease, 135. Treatment, 136. Pre- 
lacrimal abscess, 137. Stricture of the nasal duct, 137. Its eti- 
ology, 137. Symptoms and consequences, 138. Treatment, 140. 
The efficacy of thorough dilatation by means of probes large 
enough to restore the normal caliber of the duct, 140. Author's 
series of lacrimal probes, 141. Electrolysis, 149. Removal of 
the lacrimal gland, 149. Excision of the lacrimal sac and its 
destruction with the actual cautery, 149. Dacryocystitis and 
occlusion of the nasal duct in the new-born, 150. 



SYNOPSIS OF CONTENTS. 3 

CHAPTER V. page. 

Diseases of the Conjunctiva 1 51-201 

Diseases of the conjunctiva of common occurrence, 151. Im- 
portance of a correct diagnosis in dealing with them, 151. Signs 
and symptoms of inflammation of the conjunctiva, 151. Severe 
remedies, which cause pain and increase photophobia and lacri- 
mation, rarely indicated, 152. Hyperemia of the conjunctiva, 
152. Conjunctivitis, 154. Catarrhal conjunctivitis, 154. Puru- 
lent or gonorrheal conjunctivitis, 158. Ophthalmia neonato- 
rum, 165. Croupous conjunctivitis, 168. Diphtheritic con- 
junctivitis, 169. Follicular conjunctivitis, 173. Trachomatous 
conjunctivitis, 1 74. Serious consequences to which it gives rise, 
174. Vernal conjunctivitis, 183. Bulbar and palpebral types, 
183. Phlyctenular conjunctivitis, 186. Of constitutional origin, 
186. Toxic conjunctivitis, 192. Argyria conjunctivae, 193. Sub- 
conjunctival hemorrhage, 193. Pinguecula, 194. Pterygium, 
195. Author's view of its etiology', 196. Pseudo-pterygium, 197. 
Operative treatment of pterygium, 198. 

CHAPTER VI. 
Diseases of the Cornea and Sclera 202-245 

Diseases of the Cornea. 

Keratitis, 202. Divisible into suppurative and non-suppurative 
keratitis, 202. Suppurative keratitis, 204. Etiology, 204. 
Tractable and intractable types, 204. Phlyctenular keratitis, 
205. Abscess and ulcer of the cornea, 207. Pathology, 207. 
Etiology, 210. Often of traumatic origin, 211. Treatment, 
local and constitutional, 211. Employment of carbolic acid, 213. 
Use of thermo-cautery, 214. Keratomalacia, 215. Neuropathic 
keratitis, 216. Herpes zoster ophthalmicus, 218. Post-malarial 
keratitis, 220. Dendritic keratitis, 220. Herpes cornece febri- 
lis, 220. Non-suppurative keratitis, 233. Interstitial keratitis, 
223. Always dependent upon inherited syphilis, 223. Obstin- 
acy its chief characteristic, 225. Though ultimate prognosis 
good, 226. Treatment, 227. Pannitic keratitis, 231. Can- 
thotomy in treatment of pannitic keratitis, 233. Opacities 0} the 
cornea, 235. Arcus senilis, 235. Nebulas, Maculce, Leucomata, 
236. Leucoma adherens, 236. Staphyloma 0} the cornea, 239. 
Etiology, 238. May be partial or complete, 238. Conical 
cornea, 241. Attended by a high degree of myopia, 241. 

Diseases of the Sclera. 

The tough and non-vascular sclera not often the seat of disease, 
242. Scleritis, 242. Acute, diffuse scleritis, 242. Commonly 
of rheumatic origin, 242. Chronic scleritis, 243. Complicated 
by involvement of the cornea, 213. Episcleritis, 244. 



4 SYNOPSIS OF CONTENTS. 

CHAPTER VII. page. 

Diseases of the Iris and Ciliary Body 246-274 

Diseases of the Iris. 

Iritis, 246. Diagnostic signs and symptoms, 246. Etiology, 
248. Consequences of neglected iritis, 250. Varieties of iritis, 

250. Plastic, serous, and purulent iritis, 250. Rheumatic iritis, 

251. Gonorrheal iritis, 251. " Trophic " nerve iritis, 252. Serous 
iritis, 252. Plastic iritis, 253. Syphilitic iritis, 254. Iritis 
condylomatosa, 255. Iritis gummosa, 255. Varieties of "tro- 
phic" nerve, or neuropathic, iritis, 255. Sympathetic iritis 
{sympathetic ophthalmitis), 256. Etiology, 256. Sympathetic 
irritation, 257. Iritis due to herpes zoster ophthalmicus, 259. 
Spongy iritis, 259. Chronic iritis, 260. Treatment of the 
different varieties of iritis, 260. 

Diseases of the Ciliary Body. 

Cyclitis, 268. Plastic cyclitis, 268. Purulent cyclitis, 268. 
Serous cyclitis, 268. Treatment of the several varieties of 
cyclitis, 269. Tumors of the ciliary body, 269. Often of ma- 
lignant type, 269. An early diagnosis of the utmost importance, 
269. Can be made only with the aid of the ophthalmoscope, 
269. 

CHAPTER VIII. 

Glaucoma 275-294 

Importance of an early diagnosis, 275. Consequences of failure 
to recognize glaucoma in its incipiency, 275. Hardening of the 
eyeball the essential feature of glaucoma, 275. Impairment of 
vision in glaucoma, 275. Primary glaucoma, 276. Secondary 
glaucoma, 276. Primary glaucoma extremely rare in persons 
under thirty years of age, 276. Secondary glaucoma may mani- 
fest itself at any period of life, 276. Varieties of primary glau- 
coma, 276. Buphthalmos, 276. Symptoms, subjective and 
objective, of inflammatory glaucoma, 277. Prodromal symp- 
toms, 279. Factors which have to do with precipitating the 
acute exacerbations of glaucoma, 280. Consequences of un- 
checked inflammatory glaucoma, 281. Inexcusable mistakes 
made in diagnosticating glaucoma, 281. Glaucoma to be sus- 
spected whenever a painful inflammation of the eye, attended 
by impairment of sight, is encountered in an individual who has 
reached middle life, 281. Etiology of inflammatory glaucoma, 
281. Accommodative strain an important factor in the causa- 
tion of glaucoma, 285. Influence of mydriatics in precipitating 
an attack of glaucoma, when a predisposition to the disease 
exists, 285. Contraction of the visual field in glaucoma, 286. 
Treatment of inflammatory glaucoma, 287. Iridectomy the sov- 



SYNOPSIS OF CONTENTS. 

PAGE. 

ereign remedy, 287. The value of myotics in glaucoma, 288. 
Nature of their action, 288. Manner of their employment, 288. 
Dionin useful in conjunction with eserin, 289. Other non-opera- 
tive measures useful in glaucoma, 289. Importance of correcting 
refractive and muscular anomalies in the incipient stage of glau- 
coma, 290. Simple glaucoma, 291. Symptoms and clinical 
history, 291. The ophthalmoscope and perimeter necessary to 
its diagnosis, 291. Treatment, 292. Iridectomy not the effec- 
tive remedy it is in the inflammatory type of the disease, 292. 
Sympathectomy of doubtful value, 293. The systematic use 
of eserin, 293. The constitutional measures indicated, 293. 
Secondary glaucoma, 293. Etiology, 293. Symptoms and 
consequences, 294. Treatment, 294. 



CHAPTER IX. 
Diseases of the Crystalline Lens and Vitreous Humor 2 95~337 

Diseases of the Crystalline Lens. 

Anatomy and histology of the lens, 295. Growth of the lens, 295. 
Changes which it undergoes with advancing age, 296. Signifi- 
cance of these changes, 297. With reference to presbyopia, 297. 
With reference to the development of cataract, 297. Nutrition of 
the lens, 297. Cataract, 297. Origin of the name, 297. Mis- 
taken views of the Greeks and Romans as to the real nature of 
cataract, 297. Though encountered most frequently in old age, 
occurs at all periods of life, and may be of congenital origin, 298. 
Different classifications of cataract, 298. Senile or hard cata- 
ract, 298. Juvenile or soft cataract, 298. General cataract, 
298. Partial cataracts, 298. Varieties of partial cataract, 298. 
Zonular cataract, 299. Anterior polar cataract, 299. Posterior 
polar cataract, 299. Congenital cataract, 299. Idiopathic cata- 
ract, 299. Complicated cataract, 299. Traumatic cataract, 299. 
Immature, mature, and hypermature cataract, 299. Secondary 
or capsular cataract, 299. General cataract, 299. Features com- 
mon to the several varieties of general cataract, 299. Progressive 
impairment of vision in general cataract, 299. Characteristics 
of soft and of hard cataract, 301. " Second sight" a premonitory 
symptom of senile cataract, 302. Etiology of general cataract, 
302. The development of cataract a degenerative, not an inflam- 
matory, process, 302. Faulty nutrition of the lens the immediate 
cause of cataract, 302. This may be the result of a constitu- 
tional disorder, of senile decay, or of pathological changes in the 
eye itself, 302. Life-long accommodative strain a not unimpor- 
tant factor in the causation of senile cataract, 303. Etiology of 
traumatic cataract, 303. Diagnosis of cataract, 304. Assistance 
afforded by oblique illumination and the instillation of a mydri- 



SYNOPSIS OF CONTENTS. 

PAGE. 

atic, 304. Determination of the maturity of cataract, 307. 
Treatment of cataract, 310. Improvement in vision in incipient 
cataract from the use of a mydriatic, 310. Discission, the pro- 
cedure applicable to soft or juvenile cataract, 314. Extraction, 
applicable to hard or senile cataract, 315. Simple and com- 
bined extraction, 315. The success which attends extraction of 
cataract at the present day, 316. Conditions which militate 
against the success of the operation, 316. Linear extraction, 
319. Suction extraction, 319. Partial Cataract, 320. Ante- 
rior polar cataract, 320. Pyramidal cataract, 321. Posterior 
polar cataract, 322. Zonular cataract, 324. Treatment of the 
several varieties of partial cataract, 325. Capsular cataract, 
326. Etiology and treatment of capsular cataract, 326, 327. 
Dislocation of the crystalline lens, 327. May be complete or 
incomplete, 327. May be forward, into the anterior chamber, 
or backward, into the vitreous chamber, 327. Effect upon vis- 
ion, 329. Treatment, 331. 

Diseases of the Vitreous Humor. 

Pathological" changes in the vitreous humor usually due to trau- 
matism or to pre-existent disease of the uveal coat or retina, t,2>Z' 
Purulent panophthalmitis, 333. Treatment, 334. Fluidity 
of the vitreous humor, 334. Opacities of the vitreous humor, 334. 
M usees volitantes, 335. Hemorrhage into the vitreous humor, 
336. Etiology, 336. Treatment, 337. 



CHAPTER X. 

Diseases or the Choroid Coat, Retina, and Optic Nerve 338-387 

General description of the symptoms indicative of disease of the 
choroid, retina, and optic nerve, which, when taken into ac- 
count, enable the general practitioner, even without the aid of 
the ophthalmoscope, to reach an approximately accurate diag- 
nosis, 338. 

Diseases of the Choroid Coat. 
Choroiditis, 340. May be plastic, purulent, or serous in type, 
340. Purulent choroiditis, synonymous with purulent panoph- 
thalmitis, described in Chapter IX, 340. Serous choroiditis, syn- 
onymous with uveitis, considered in Chapter VII, 340. Plastic 
choroiditis, 340. Frequently dependent upon syphilis, 340. 
Syphilitic choroiditis, 340. Commonly involves the retina, 340. 
Runs a tedious course, 341. Both eyes usually affected, 341. 
If neglected may lead to loss of sight and to the development of 
cataract, 342. Choroiditis of high myopia, 342. Traumatic cho- 
roiditis, 342. Miliary choroido-retinitis, 343. A not uncommon 
consequence of accommodative strain, 343. Probably a factor, 



SYNOPSIS OF CONTENTS. 



of no mean importance, in the causation of glaucoma and of 
senile cataract, 344. Treatment of the several varieties of cho- 
roiditis. 345. Tumors of the choroid, 348. 

Diseases of the Retina. 

Retinitis, 348. Divisible into primary and secondary retinitis, 
348. Also into serous and parenchymatous retinitis, 348. Ret- 
initis unattended by photophobia or pain, 348. Impairment 
of vision the chief subjective symptom, 348. Causes of primary 
and of secondary retinitis, 349. Retinitis albuminurica, 349. 
Occurs in all forms of disease of the kidney accompanied by al- 
buminuria, and not infrequently as an early symptom, 349. Also 
in the albuminuria of pregnancy and of scarlatina, 349. Nearly 
always bilateral, 349. Uremic amblyopia, 351. Treatment 
to be directed to the nephritis and to the general condition of the 
patient, 351. Diabetic retinitis, 351. Is always bilateral, 351. 
Not infrequently accompanied by cataract, and occasionally by 
iritis or glaucoma, 351. Prognosis unfavorable, 352. Treat- 
ment, 352. Leucocythemic retinitis, 352. Retinitis of perni- 
cious anemia, 352. Syphilitic retinitis, 353. Energetic anti- 
syphilitic treatment demanded, 353. Retinitis from exposure 
of the eyes to intense light, 353. Usually most marked in the 
macular region, 353. Treatment, 354. Retinitis pigmentosa, 
354. Begins in early childhood, 354. May be congenital, 354. 
Often associated with congenital anomalies of the eye or of other 
organs, 354. Met with in the offspring of consanguineous mar- 
riages, 354. Night-blindness an early symptom, 355. Grad- 
ual contraction of visual field, with ultimate loss of central 
vision, 355. Treatment of little avail, 356. Embolism of the 
central artery of the retina, 357. Characterized by sudden loss 
of sight of the affected eye, 357. Striking ophthalmoscopic 
picture, exhibiting the "cherry -red spot at the macula," 357. 
Treatment, 358. Thrombosis of the central artery of the retina, 
359. Probably the cause of the sudden loss of sight occasionally 
observed in acute anemia, 359. Symptoms and ophthalmo- 
scopic picture similar to those observed in embolism, 359. 
Thrombosis of the central retinal vein, 359. Usually met with in 
elderly persons with organic heart disease or angiosclerosis, 359. 
May be caused by the extension of facial erysipelas to the orbit, 

359. The ophthalmoscope shows enormous distention and 
great tortuosity of the retinal veins, with numerous hemorrhages 
scattered over the entire fundus, 360. Treatment of little avail, 

360. Detachment of the retina, 360. Its etiology, 361. Far- 
fetched theories advanced to explain its occurrence unsatisfying, 

361. Oftenest met with in high myopia, 361. May result from 
trauma, 361. Occurs in conjunction with intraocular growths, 

362. Symptoms, 362. Annoying disturbance of vision to 



PAGE. 



SYNOPSIS OF CONTENTS. 



which it gives rise, 363. Prognosis most unfavorable, 363. 
Operative and non-operative treatment, 364. Glioma of the 
retina, 364. One of the most malignant of pathological new- 
growths, 364. Possibility of diagnosticating it by daylight in- 
spection, with the assistance of a mydriatic, 365. Symptoms 
and course of the disease, 365. Enucleation of the eye at the 
earliest moment possible indicated, 366. But recurrence of the 
growth, especially in the brain, to be feared, 367. A disease 
of childhood, 365. 

Diseases of the Optic Nerve. 
Optic neuritis, 367. Divisible into retrobulbar neuritis and intra- 
ocular neuritis, 367. The latter again divisible into papillitis, 
or choked disc, and descending optic neuritis, 367. Etiology of 
descending optic neuritis and of choked disc, 368. Choked 
disc {papillitis), 370. Vision at first may be but slightly im- 
paired, though pronounced fundus changes are present, 371. 
Usually dependent upon intracranial tumor, 371. Present in 
from eighty to ninety per cent, of intracranial new-growths, 371. 
Descending optic neuritis, 372. Fundus changes less marked 
than in choked disc, 372. Oftenest due to basilar meningitis 
attended by inflammation of the contiguous brain substance, 
372. The prognosis in both choked disc and descending optic 
neuritis largely dependent upon the nature of the lesion which 
has led to their development, 372. Treatment, 373. Retro- 
bulbar optic neuritis (orbital neuritis), 374. Occurs under two 
forms — Acute retrobulbar neuritis and chronic retrobulbar neu- 
ritis, or toxic amblyopia, 374, 375. In each the orbital portion of 
the nerve is first involved, and especially the papillo-macular 
fibers, 375. Acute retrobulbar neuritis, 374. Etiology, 374. 
Symptoms and course of the disease, 374, 375. Treatment, 375. 
Chronic retrobulbar neuritis (toxic amblyopia), 375. Etiology, 
375. Symptoms, 375. Ophthalmoscopic changes observed, 

377. Prognosis and treatment, 377. Quinin blindness, 377. 
Atrophy 0} the optic nerve, 3 78. Primary (simple) atrophy, 

378. Nearly always bilateral, 379. Etiology, 379. Early 
symptoms, 379. Ophthalmoscopic signs, 379. Treatment 
usually of little avail, 381. Consecutive atrophy of the optic 
nerve (inflammatory atrophy), 381. Causes, 381. Sub- 
jective and objective symptoms, 381. Diagnosis to be estab- 
lished only by the ophthalmoscope, 381. Usually distinguish- 
able from simple atrophy, 381. Prognosis not so unfavorable 
as in simple atrophy, 382. Treatment, 382. Hemianopsia, 
383. Varieties, 383. Binasal and horizontal hemianopsia, 
uncommon, 384. Homonymous lateral hemianopsia and bi- 
temporal hemianopsia more frequently encountered, 385. Ex- 
planation of the occurrence of the different varieties of hemian- 



PAGE. 



SYNOPSIS OF CONTENTS. 9 

PAGE. 

opsia, 3S5. Homonymous lateral hemianopsia, 385. Causes, 
385. Early and later symptoms, 385. Central vision seldom 
lost, 385. Transient hemianopsia, 386. Bitemporal hemi- 
anopsia, 386. Treatment, except in cases of syphilitic origin, 
usually without avail, 387. 

CHAPTER XI. 
Anomalies of Refraction* and Accommodation 388-437 

Anomalies of Refraction. 

Prevalent misconceptions in regard to the measurement and 
correction of the refractive and muscular anomalies of the eyes, 

388. No branch of ophthalmic practice more imperatively 
demands especial skill and training, 388. The harm which 
comes from the hap-hazard methods of the tyro who, after a few 
weeks' instruction in an "optical college," announces himself 
as an "ophthalmic optician," 388. Importance of the role 
errors of refraction play in the causation of ocular maladies, 

389. Also in the production of maladies other than those of the 
eye, though, as to these, there has been much exagger- 
ation. 389. Eye-strain a common cause of headache, neuras- 
thenia, vertigo, disturbance of mental concentration, etc., 390. 
Observations upon some of the prevalent misconceptions regard- 
ing refractive errors, and concerning the indication for "glasses" 
and their influence upon sight, 391. Errors of refraction rarely 
"outgrown," and not to be gotten rid of by "rest of the eyes," 
massage, the application of drugs, etc., 391. Glasses not to be 
regarded as a dernier ressort, 391. Glasses do not "weaken the 
sight," as is popularly supposed, 391. No foundation for the 
belief that if glasses are worn in childhood a time may come 
when it will be impossible to obtain them of the required strength, 

391. Glasses given not merely to sharpen vision but to relieve 
eve-strain, 391. Often demanded when there is normal acute- 
ness of sight, 392. Exert a marked influence in checking the 
progress of myopia, 392. But it is not to be expected that they 
will "cure" the refractive fault for which they are prescribed, 
and only exceptionally does it happen that they can be put aside, 

392. Not all eyes needing glasses make a direct appeal for their 
aid, 392. Not infrequently, when the remote consequences of eye- 
strain are pronounced, there may be no complaint of the eyes 
themselves, 392. Emmetropia, 393. Ametropia, 394. A gen- 
eral term denoting a departure from the normal in the optical 
construction of the eye, 394. Hvpermetropia (Jar-sightednesi). 
395. The most prevalent form of ametropia, and nearly always 
of congenital origin, 395. Owing to an abnormal flatness of the 
eyeball, or a lack of refractive power in its lens system, the hyper- 



10 SYNOPSIS OF CONTENTS. 

PAGE. 

metropic eye is incapable of focusing upon the retina parallel 
rays of light, without an effort of accommodation, 395. Facul- 
tative and non- facultative hypermetropia, 395. Axial hyper- 
metropia, 397. Curvature hypermetropia, 397. The ill conse- 
quences of hypermetropia, 398. The most important factor in 
the causation of convergent squint, 398. Asthenopia, headache, 
blepharitis marginalis, etc., common consequences of the eye 
strain to which it gives rise, 398. The ill effects of the higher 
grades of hypermetropia manifest themselves in early childhood, 

398. The lower grades may cause no inconvenience until 
the presbyopic age is approached, 399. The whole treat- 
ment of hypermetropia comprised in the careful adjust- 
ment of glasses, 399. Whether these must be worn con- 
stantly, or only in near vision, will depend upon the degree 
of the refractive fault, the power of accommodation, and 
the relative strength of external and internal recti muscles, 

399. With properly adjusted glasses the hypermetropic eye 
is relieved of all strain, and is capable of doing the work which 
the normal eye does without assistance, 400. Influence which 

* the correction of hypermetropia by glasses exerts upon the de- 
velopment of convergent squint, 402. A squint, as yet not fully 
established, can always be corrected by properly adjusted 
glasses, 402. A fully established squint, only exceptionally, 402. 
More often than not hypermetropia is complicated by the co- 
existence of astigmatism, 403. For this reason, and because the 
judicious correction of hypermetropia presupposes a clear com- 
prehension of the muscular anomalies of the eye, it is manifest 
that the treatment of this very prevalent refractive fault should 
be undertaken only by the physician who has had especial train- 
ing and experience, 403. Myopia {short-sightedness), 403. 
Much less common than hypermetropia, and nearly always an 
acquired fault, 403. Owing either to the antero-posterior axis 
of the eye being too long, or to an excess of power in its lens 
system, rays of light are brought to a focus before reaching the 
retina, 403. Axial myopia, 404. Curvature myopia, 404. 
Axial myopia, the more common type, usually due to the de- 
velopment of a posterior staphyloma, 404. Conical cornea a 
striking example of curvature myopia, 405. Etiology of axial 
myopia, 405. Disturbed relation of accommodation and con- 
vergence in myopia, 407. A cause of asthenopia, and may lead 
to the development of divergent squint, 408. Myopia oc- 
casionally a result of acute systemic disease, 408. Origin of the 
name "myopia," 409. The ophthalmoscope affords the 
readiest means of diagnosticating myopia, 409. Treatment, 409. 
Whether the defect shall increase to the danger-point, or shall 
be arrested before the deeper structures of the eye have suffered 
irreparable damage, hinges upon the skill exercised in its cor- 



SYNOPSIS OF CONTENTS. II 

PAGE. 

rection by glasses, 410. Importance of correcting associated astig- 
matism, and of taking into account the muscle-balance in both 
far and near vision, 410. The widespread belief that in myopia 
glasses are called for only in distant vision, seldom well founded, 
411. In distant vision they are a convenience; in near vision, 
a therapeutic agent of great value, 41 1 . Operative procedures 
in myopia, 413. When there is pronounced insufficiency of 
the internal recti muscles a guarded tenotomy of one or both of 
the opponent muscles may be indicated, 413. Removal of the 
crystalline lens in high myopia a procedure attended by con- 
siderable risk, and of doubtful utility, 413. Astigmatism, 413. 
Definition of the term, 413. Regular astigmatism , 413. Com- 
monly due to asymmetry of the cornea, less often to asymmetry or 
obliquity of the lens, 413. Usually a congenital and often an 
inherited fault, 413. Disturbance of vision in astigmatism, 414. 
Latent astigmatism, 414. Explanation of the asthenopia com- 
monly associated with astigmatism, 414. Improvement in 
vision secured by nipping the lids, 414. Varieties of regular astig- 
matism, 415. Simple astigmatism, 415. Compound astigma- 
tism,^^,. Mixed astigmatism, 415. Astigmatism " according to 
the rule " and "against the rule," 415. Importance of correcting 
even the lowest degrees of astigmatism "against the rule," 416. 
The apparent increase of astigmatism usually due to the total 
defect becoming manifest, as a result of correcting glasses, 416. 
Acquired astigmatism commonly the result of traumatism or of 
ulcerative keratitis, 417. Astigmatism capable of giving rise to 
pronounced asthenopic symptoms, not incompatible with normal 
acuteness of vision, 417. Simple method of detecting the pres- 
ence of astigmatism marked in degree, 417. Astigmatism a prev- 
alent fault, and often a chief factor in the causation not only 
of many ocular maladies but of many obscure disturbances of 
the nervous system, 418. Treatment of astigmatism, 419. Its 
correction by cylindrical glasses, 419. These commonly bring 
vision up to the normal standard, and, more important still, by 
eliminating the previously existing accommodative strain, do 
away with the asthenopia, headache, etc., 420. Methods of 
detecting and measuring astigmatism, 421. Anisometropia, 
424. A not uncommon cause of asthenopia, 424. Exception- 
ally it proves a blessing in disguise, 424. Indications for its cor- 
rection by glasses, 424. 

Anomalies of Accommodation. 

Theory of the accommodation of the eye as propounded by 
Helmholtz, 426. Different ways in which the ability of the eye 
to change its focus may be impaired, 427. Presbyopia (old- 
sightedness), 427. Due to loss of elasticity of the lens, 427. 
Commonly manifests itself about the forty-fifth year, and 



12 SYNOPSIS OF CONTENTS. 

PAGE. 

interferes with the sharp-seeing of near objects, 428. Its on- 
coming influenced by the existence of refractive errors, 428. 
Cannot be cured or its development postponed by massage, the 
use of "eye-cups," etc., 429. Glasses the only remedy, 429. 
Fallaciousness of the common belief that the needed glasses can 
be "fitted" by anyone who "carries a stock" of spectacles, 429. 
As presbyopia is a progressive condition, the glasses prescribed 
must be increased in strength from time to time, 429. Bifocal 
lenses in presbyopia associated with refractive faults, 430. 
Paralysis of the ciliary muscle, 430. Diphtheria and syphilis 
the commonest causes, 431. Sudden impairment of near vision 
the most prominent symptom, 431. Prognosis usually favor- 
able, 431. Treatment, 432. Spasm of the ciliary muscle, 432. 
Commonly the result of uncorrected refractive errors, 432. 
Treatment, 433. Subnormal accommodative power, 433. A 
not infrequent cause of asthenopia in young persons, 433. Due 
to congenital lack of elasticity of the crystalline lens or to insuf- 
ficiency of the ciliary muscle, 433. Rules for its detection and 
measurement, 435. Its treatment by convex glasses and by 
spheroprismatic lenses, 436, 437. Method of determining the 
required lenses, 436. When associated with faults of refraction, 
different glasses may be required for far and near vision, even in 
quite young subjects, 436, 437. 



CHAPTER XII. 

Muscular Anomalies of the Eyes 438-479 

Manifest and latent muscular anomalies, 438. May be of par- 
alytic or of congenital origin, or a consequence of refractive errors, 
438. The manifest muscular anomalies — the actual squints — not 
provocative of eye-strain, 439. The latent muscular anoma- 
lies — the several varieties of heterophoria — on the other hand, 
commonly give rise to marked asthenopic symptoms, 439. 

Manifest Muscular Anomalies. 

Paralytic squint, 440. The nervous supply of the extrinsic 
ocular muscles, 440. Etiology of paralytic squint, 441. Par- 
alysis of the external rectus muscle, 442 . Symptoms, diagnosis, 
and treatment, 443. Paralysis of the superior oblique muscle, 
444. Paralysis of the oculomotorius, 444. Oftenest dependent 
upon acquired syphilis, 444. Varieties, 445. Frequently at- 
tended by ptosis, 445 . Ophthalmoplegia totalis, 445. Ophthal- 
moplegia externa, 445. Ophthalmoplegia interna, 445. Usually 
caused by diphtheria, 445 . Treatment of the different varieties 
of paralysis of the oculomotorius, 446. Operative procedures 
not to be resorted to hastily, 446. Conjugate ocular paralyses, 



SYNOPSIS OF CONTENTS. 13 

PAGE. 

446. Nystagmus, congenital and acquired, 447. Concomitant 
squint, 448. How different from paralytic squint, 448. May 
be constant, periodic, or alternating, 448. Etiology of concomi- 
tant squint, 448. Amblyopia of the squinting eye, 449. Not 
an example of " amblyopia exanopsia, " 449. Commonly a con- 
sequence, not a cause, of the squint, 449. Explanation of its de- 
velopment, 449. Significance of its regional character, 450. 
Tests for the detection of squint, 452. Convergent concomitant 
squint, 453. Develops in early childhood, 453. The suf- 
ficiency of Donders' explanation of why many hypermetropes 
do not squint, 453. Hypermetropia the most important factor 
in the causation of convergent squint, 453. The coexistence 
of insufficiency of the external recti muscles or of subnor- 
mal accommodative power greatly increases the likelihood 
of its occurrence, 454. Explanation of the occurrence 
of convergent squint in high myopia, 454. Treatment, 
operative and non-operative, of concomitant convergent 
squint, 455. Early correction of the squint desirable, 455. 
Established convergent squint seldom corrected without opera- 
tion, 455. Importance of determining the refractive condition 
and visual acuteness in all cases of squint, 455. Periodic conver- 
gent squint always capable of correction by glasses alone, 456. 
Re-establishment of binocular vision the ideal result aimed at in 
the treatment of squint, 456. Factors which sometimes render 
this difficult of accomplishment, 456. Operative treatment of 
convergent squint, 457. "Tenotomy" preferable to "ad- 
vancement," 457. Arlt's method of performing tenotomy the 
simplest and best, 457. Description of his operation and 
enumeration of the instruments required in its performance, 457. 
The unsightly sinking of the caruncle in awkwardly executed 
tenotomies upon the internal rectus, 459. How obviated, 459. 
Essential difference between the modern operation of tenotomy 
and the clumsy procedures in vogue fifty years ago, 462. Di- 
vergent concomitant squint, 463. Myopia, congenital or ac- 
quired insufficiency of the internal recti muscles, and marked 
difference in the visual acuteness of the eyes the most potent fac- 
tors in its production, 463. Usually develops in adult life, 464. 
May be present only in near vision, 464. Regional amblyopia, 
as observed in convergent concomitant squint, rarely present, 
464. Treatment, 464. Exceptional conditions which render 
its correction, without operation, possible, 464. Its correction in 
high myopia often inadvisable, 465. Not so easily corrected by 
tenotomy as convergent squint, 465. Tenotomy must often 
be supplemented by advancement, 465. Free tenotomy of both 
external recti the best procedure in some instances, 465. Ver- 
tical concomitant squint, 466. 



14 SYNOPSIS OF CONTENTS. 



Latent Muscular Anomalies. 

Under this head are included all the varieties of heterophoria, 
466. Less frequently encountered than refractive errors, but 
as capable of producing the manifold symptoms which we have 
learned to attribute to eye-strain, 466. When associated with 
ametropia, may greatly aggravate the ill consequences of the 
refractive fault, 467. Exceptionally, may have the contrary 
effect, 467. Apparent and actual muscular anomalies, 467. 
How they may be distinguished, 467. Influence of refractive 
errors upon muscle-imbalance, 467. Brief mention of the tests 
employed for the detection and measurement of heterophoria, 
469. Importance of determining the muscle-balance for near, 
as well as for distant, vision, 469. Schild's pin-hole light, 470. 
Heterophoria to be corrected by glasses or by operative pro- 
cedure, 470. Exophoria, 471. Frequently only apparent, and 
dependent upon myopia, 472. Treatment by glasses, tenotomy, 
and, exceptionally, by advancement, 472. Esophoria, 473. 
Hypermetropia and hypermetropic astigmatism important factors 
in its causation, 473. In every case their existence should be 
suspected, and carefully searched for, 473. Not always depend- 
ent, however, upon these faults, 474. Marked examples met 
with in emmetropia, 474. Here there is actual insufficiency of 
the external recti muscles, 474. The tests for esophoria should 
be applied in near, as well as in distant, vision, 474. Treat- 
ment, 474. Exact determination of the refractive condition of 
the eyes the first step, 474. If a marked degree of hyperme- 
tropia is present, it is best to correct this by glasses and postpone 
operative procedure until the effect is observed, 475. When 
relief is not secured in this way, prisms may be combined with 
the glasses required for the correction of the refractive fault or 
a tenotomy performed, 475. When no error of refraction exists 
the choice lies between prisms or a tenotomy, and hinges upon 
the degree of the muscle-fault, 475. Conservatism to be com- 
mended in operating for latent muscular anomalies, 476. But, 
when the indications are clear, the fullest confidence may be felt 
that a well executed tenotomy will result in marked benefit, 476. 
By " tenotomy " is meant a real division of the tendon, 476. No 
excuse for " graduated" or partial tenotomies, 476. A " guarded 
tenotomy" not infrequently indicated, 477. Actual squint often 
corrected by less free tenotomizing than is sometimes demanded 
in latent muscular faults, 477. Hyperphoria, 477. Definition, 
477. Etiology, 477. Capable of producing all of the distress- 
ing symptoms arising from eye-strain, 477, 478. Should be 
sought for in every case of asthenopia, 478. Exceptionally pres- 
ent only in near, or only in distant, vision. Should therefore be 
sought for in both, 478. Maddox's multiple rod the best test for 



SYNOPSIS OF CONTENTS. 15 

PAGE. 

hyperphoria, 478. In the test for near vision, should be used in 
conjunction with the pin-hole light of Schild, 478. Treatment, 
478. The lower degrees should be corrected by prisms, 478. 
Operation indicated only when the defect is pronounced, 478. 

CHAPTER XIII. 

Injuries of the Eye and its Appendages 480-504 

Injuries of the eyelids, 480. May result in malposition of the 
lid margins and lacrimal puncta, also in anchyloblepharon or 
symblepharon, 480. Burns of the lids from caustic agents, 
molten metal, etc., 481. Treatment, 482. Value of Thiersch 
grafts, 483. Injuries of the bulbar conjunctiva, 483. Danger 
of symblepharon resulting, 483. Superficial injuries of the 
cornea, 485. Usually not of serious moment unless infection 
occurs, 485. Method of applying carbolic acid under such 
circumstances, 486. Other remedial measures, 486. Super- 
ficial lodgment of foreign bodies in the eye, 486. One of the com- 
monest accidents to which the eye is subject, 486. Nearly always 
found adherent to the cornea or upon the under surface of the 
upper lid, 487. Occasionally find their way into the canaliculus, 

488. Fragments of grass seed hulls sometimes remain attached 
to the cornea for months, 488. Their true character easily over- 
looked, 488. Little reliance to be placed upon the convictions of 
the patient as to the presence or non-presence of a foreign body, 

489 . B est methods of removing foreign bodies from the eye, 490 . 
Cocain required only when they are adherent to the cornea, 490. 
Contusions of the eye, 491. Though of common occurrence, sel- 
dom of serious moment because of the protection afforded by the 
bony orbital margin and the elastic cushion of fat upon which 
the eyeball rests, 491. Rupture of the eyeball, dislocation of the 
lens, traumatic cataract, laceration of the iris, and detachment 
of the retina among the serious consequences apt to result from 
severe contusions, 491. Commoner causes of such injuries, 
493. Treatment demanded in slight and in severe contusions, 

493. Penetrating wounds of the eye, 494. Always of serious 
concern, are made more so because of the danger of infection, 

494. Wounds of the cornea, iris and lens, 494. Of the sclera 
and ciliary body, 494. Of the sclera, choroid, and retina, 495. 
Consequences of such injuries, 495. Treatment, 495. Anti- 
septic precautions of the first importance, 495. Wounds of the 
eye complicated by the lodgment of foreign bodies within the ball, 
497. Of still more serious moment, 497. Much depends, 
however, upon the nature of the foreign body and upon its loca- 
tion, 497. Least dangerous when sterile and when incapable of 
undergoing chemical change, 497. May find lodgment in the 
iris, the lens, the vitreous body, the deeper tunics of the eye, or, 



l6 SYNOPSIS OF CONTENTS. 



PAGE. 



more rarely, may fall into the anterior chamber, or pass through 
the eye and reach the depths of the orbit, 498. Treatment, 499. 
Great assistance afforded by skiagraphy and the electro-magnet, 
499. Nowadays, eyes often saved, and with useful vision, 
which formerly were enucleated without hesitation, 499. Pain 
reaction test, 500. Removal of non-magnetic foreign bodies, 
502. Difficulties which attend the removal of foreign bodies 
from the anterior chamber, 502. Gunshot wounds, 503. 
Wounds caused by penetrating foreign bodies may be of such a 
character as to demand immediate enucleation of the eye, 504. 
This is especially the case when their nature is such as to render 
the development of sympathetic ophthalmitis not improbable, 
5°4- 

Appendix 505-520 

Formulae, for the most part in general use, of proved efficacy 
in the treatment of diseases of the eye, 505. 

Index 521 



PREVALENT DISEASES OF 
THE EYE. 



CHAPTER I. 



GENERAL OBSERVATIONS UPON THE DIAGNOSIS 
OF DISEASES OF THE EYE, DESCRIPTION OF 
THE METHODS OF EXAMINING THE EYE AVAIL- 
ABLE TO THE GENERAL PRACTITIONER. 

The weak point of the general practitioner in dealing 
with eye diseases is, unquestionably, in reaching a 
correct diagnosis; and this is not surprising in view of 
the fact that in most instances he works without the 
help of the ophthalmoscope, the trial case, and the 
various contrivances for testing the central and peri- 
pheral visual acuteness, the muscle balance, etc., aids 
which the specialist in diseases of the eye always has 
at command, and without which even he would often 
be at fault. But, it must be confessed, the general 
practitioner's errors of diagnosis are not always limited 
to the class of cases in which these aids are essential. 

For example, he not infrequently fails to draw a 
distinction between the several varieties of conjunc- 
tivitis, and, in consequence, is led into errors in the 
therapeutic measures which he employs. Again, he 
mistakes a corneal inflammation or an iritis, with its 
attendant conjunctival injection, for a simple con- 
junctivitis, with still more serious consequences; or, 
in order to avoid this mistake, he goes to the other 

2 17 



IS PREVALENT DISEASES OF THE EYE. 

extreme, and causes his patient much unnecessary 
inconvenience by prescribing atropin when only a mild 
astringent is called for. In other instances, he mis- 
takes the photophobia, lacrimation and hyperemia of 
the conjunctiva due to the presence of a foreign body 
upon the cornea or beneath the upper lid for a com- 
mencing ocular inflammation, and treats it accordingly, 
without success. A chronic conjunctivitis or blepharitis, 
dependent upon an error of refraction or a muscular 
anomaly or secondary to disease of the lacrimal 
apparatus, is dealt with without reference to its primary 
cause and, therefore, to no effect. 

Still more disastrous in its results is the failure of the 
general practitioner to recognize promptly inflamma- 
tory glaucoma. Not infrequently this disease is mis- 
taken for iritis or keratitis, and atropin, the remedy 
distinctly contraindicated, is prescribed, or, in the 
quiet periods between the inflammatory outbreaks, 
owing to the apparent or actual loss of transparency 
of the crystalline lens, for cataract, which usually leads 
to the patient's being advised to defer any operative 
procedure until the supposed cataract is "ripe/' 
Under such circumstances, when the case ultimately 
comes under the observation of the ophthalmic sur- 
geon the eye too often is absolutely blind, and nothing 
that he can do is of avail, at least so far as the restora- 
tion of sight is concerned. To mistake an acute 
glaucomatous attack for severe facial neuralgia, as 
sometimes happens, though a most unfortunate mis- 
take, is less reprehensible; for in neuralgia of the fifth 
nerve the eye upon the affected side is not infrequently 
injected, sensitive to the touch and photophobic, and 
the pain experienced in the two conditions is of much 
the same character. 



GENERAL OBSERVATIONS UPON DIAGNOSIS. 19 

It is with the view of helping the general practitioner 
to avoid such mistakes as have been enumerated and 
others of similar character, and, further, to enable 
him to recognize the probable existence of other troubles, 
such as refractive and muscular anomalies and dis- 
eases of the deeper structures of the eye — as to which 
he can hardly be expected to make a definite and exact 
diagnosis, and which, therefore, if he is conscientious 
and discreet, he will not be inclined to treat — that this 
chapter is written. 

Doubtless, it would be an excellent thing if every 
physician were an expert ophthalmoscopist; but, 
however desirable, there are not many who would con- 
tend that, for the present at least, this is practicable. 
As a matter of fact, the number of general practitioners 
at the present day who are, or who are ever likely to be, 
sufficiently versed in the use of the ophthalmoscope 
to make it of any real diagnostic value to them is, 
relatively, so small that it may be treated as a neg- 
ligible quantity. Such being the case, it is assumed 
throughout this work — which, as has been stated, is 
designed solely for physicians engaged in general 
practice — that the reader is not skilled in the use of 
the ophthalmoscope; and this has materially modified 
the treatment of several important subjects. 

METHODS OF EXAMINING THE EYE. 
Oblique Illumination. — Although skill in the em- 
ployment of the ophthalmoscope, as has just been said, 
is not likely to be acquired by very many general 
practitioners, there is a most valuable method of exam- 
ining the eye which every physician can easily master, 
and which he will find of the greatest possible assistance 
as an aid to diagnosis. I refer to what is known as 



20 PREVALENT DISEASES OF THE EYE. 

oblique illumination of the eye. A room which can be 
made, at least, moderately dark, a brightly burning 
candle, a lamp (a " student's lamp" is the best) or a 
steadily burning gas-light, and a biconvex lens of from 
two to two and a half inches diameter and of two and 
a half inches focal length, are all the paraphernalia 
necessary, and to employ these to good purpose but 




Fig. i. — Examination of the eye by oblique illumination. 

little practice (and for this the normal eye will suffice) 
is required. 

"Oblique illumination" means, simply, the focusing, 
by means of the lens just describe'd, of a beam of arti- 
ficial light upon the anterior structures of the eye. 
The examination is most conveniently made, as is shown 
in the accompanying illustration (Fig. i), by having 
the light to the left and slightly in front of the patient, 
approximately on a level with his eyes, and at a dis- 



METHODS OF EXAMINING THE EYE. 21 

tance of about eighteen inches from his face. The lens 
should be held between the thumb and forefinger of 
the examiner, with one of its convex surfaces towards 
the light, the other towards the eye to be examined, and 
at a distance of about three inches from the latter. 
The concentration of the light upon the eye can be 
regulated more accurately if the examiner steadies his 
hand by resting the ring-finger upon the patient's 
cheek. 

The great help which this method of inspection 
affords in the investigation of abnormal conditions in 
the anterior structures of the eye — that is to say, the 
cornea, anterior chamber, iris and crystalline lens — 
can scarcely be realized by those who have not employed 
it. In searching for foreign bodies, whether lodged 
upon or in the cornea, the iris, the lens or within the 
anterior chamber; in ascertaining the presence and 
character of opacities in the cornea or anterior portion 
of the lens; in examining corneal abscesses and ulcers; 
in investigating the condition of the iris and the pupil, 
determining whether suspected iritis exists, whether 
posterior synechia? have formed or hypopyon is present 
— in all these conditions, and in others likely to be met 
with from time to time, its value is hardly to be esti- 
mated. While, therefore, I do not deem it worth while 
to advise physicians in general to endeavor to become 
ophthalmoscopists, I do urgently recommend that 
every practitioner likely to be called upon to give an 
opinion regarding an injured or diseased eye should 
provide himself with the means, and acquire the easily 
gained skill, necessary to the successful employment of 
oblique illumination. 

As a further important aid to accuracy in diagnosis, 
every physician should have at hand a mydriatic which 



22 



PREVALENT DISEASES OF THE EYE. 



is evanescent in its action, such as homatropin hydro- 
bromate in one per cent, solution or euphthalmin 
hydrochlorate in five per cent, solution; for, as will 
be seen later, by its use he will often gain valuable and 
much-needed information. He should, moreover, ac- 
quire facility in everting the upper lid; in determining 
the tension of the eye; in observing the pupillary 
reaction, and in testing, roughly at least, central and 
peripheral vision. 
Eversion of the Eyelids. — To facilitate eversion of 





Fig. 2. — Eversion of the upper lid 
(Hansell and Sweet). 



Fig. 3. — Method of holding the 
everted lid (Lawson). 



the upper lid the patient should look strongly down- 
ward, without closing the eye. If the examiner now 
seizes the lashes and draws the lid away from the ball 
while at the same moment he depresses the upper edge 
of the tarsal cartilage either with a finger of his other 
hand or a slender penholder or pencil, the eversion is, 
in most instances, easily accomplished (Figs. 2 and 3). 
The inner surface of the lower lid may, of course, be 
inspected with more ease. Its eversion is effected by 
having the patient look upward, and by drawing the 



METHODS OF EXAMINING THE EYE. 



23 



margin of the lid downward and pressing it against the 
lower border of the orbit with the finger-tip. 

Tension of the Eye. — The intraocular tension or 
hardness of the eyeball, which varies greatly in different 
affections of the eye, is determined by having the 
patient look downward and making gentle pressure 
upon the eyeball, through the upper lid, with the tip 




/ ■ j 

Fig. 4. — Position of hands in determining intraocular tension. 



of the forefinger or second finger of each hand (Fig. 4). 
The pressure should alternate, not too quickly, between 
the two fingers, and should be made well back of 
the corneal border. By allowing the ring or middle 
finger of each hand to rest upon the temple or brow 
of the patient, so as to support the weight of the hand, 
the test is rendered more delicate. In recording the 
result of such an examination it is usual to employ a 



24 PREVALENT DISEASES OF THE EYE. 

capital T as an abbreviation for " tension, " +T indi- 
cating increased tension, or an abnormally hard eye- 
ball, — T, reduced tension, and Tn, normal tension. 
The numerals i, 2, 3 following -\-T or — T are used to 
indicate varying degrees of increased or reduced tension. 

Pupillary Reaction. — The patient should be seated 
facing the bright light of a window (not, however, the 
direct rays of the sun) and the pupillary reaction of each 
eye should be tested separately, the light, meantime, 
being carefully excluded from the other eye, which 
should be closed and covered by the patient's hand. 
The patient having been directed to look into the 
distance, the hand of the examiner should be held in 
front of, and quite close to, the eye under observation, 
(so close to it that the patient will not attempt to look 
at the hand — to " accommodate " for it — as this, of 
itself, would cause the pupil to contract) and then, after 
the eye has been shaded in this way for a few moments, 
the hand should be removed quickly, and the behavior 
of the pupil noted. 

Under normal conditions the pupil, which will have 
dilated considerably under the shadow of the hand, 
contracts sharply and promptly when the light is 
allowed to fall upon the eye. This is the direct reflex 
action of the pupil, caused by contraction of the sphinc- 
ter muscle of the iris. As is well known, it is due to 
the stimulation of the retina by the greater amount of 
light falling upon it, which leads, in turn, to stimulation 
of the sphincter pupillae center in the oculomotor 
nucleus. The necessity for carefully excluding the 
light from the eye not under observation while testing 
the pupillary reaction of the other eye arises from the 
fact that, normally, both pupils contract when the 
retina of either eye is stimulated by light. This is 



METHODS OF EXAMINING THE EYE. 25 

known as the indirect or consensual reflex action of the 
pupil, and is a consequence of the semi-decussation of 
the optic nerves in the chiasm. A contraction of the 
pupils also occurs in accommodation (focusing) of the 
eyes for near objects and in the convergence of the visual 
axes which usually accompanies an effort of accommo- 
dation. This is called the associated action of the 
pupils. 

Before describing the more important alterations in 
pupillary reaction due to pathological conditions, it will 
be well to mention that both the size and degree of 
reaction to light of the pupils vary greatly in persons 
who are entirely free from disease. In the first place, 
in youth the pupils are larger and respond more en- 
ergetically to light than they do in advanced life. 
Again, the size of the pupils is influenced by the state 
of refraction of the eye, being, as a rule, smaller in 
hypermetropic, and larger in myopic than in normally 
constructed, or emmetropic, eyes. Frequently, how- 
ever, the size and activity of the pupils vary markedly 
without assignable cause, just as the diameter of the 
cornea or iris varies in eyes that are entirely normal. 
In health the pupils of the two eyes are usually of the 
same size, though slight differences are not very un- 
common, and are not significant. A marked differ- 
ence in the refraction of the two eyes may cause a 
difference in the size of the pupils, the pupil being 
smaller in the eye in which a greater accommodative 
effort is required. In shape the pupils vary less than 
in size, being, in health, practically round. 

There are many pathological conditions which in- 
fluence the size, shape and reactions of the pupils. 
The iris itself may be the seat of disease; for example, 
iritis may be present, and this commonly causes con- 



26 PREVALENT DISEASES OF THE EYE. 

traction and immobility of the pupil and not infre- 
quently distortion, owing to the formation of adhesions 
between the iris and the lens capsule. On the other 
hand, when the tension of the eye becomes abnormally 
increased, as in glaucoma, the pupil is more or less 
widely dilated, is often oval in shape, and responds 
but slightly, if at all, to light. Inflammation of the 
cornea, the presence of a foreign body in the eye and, 
in fact, almost any condition accompanied by photo- 
phobia, lacrimation and ciliary irritation, if we except 
glaucoma, is attended by contraction of the pupil. 
Again, a moderately dilated and immovable pupil may 
be caused by paralysis of the sphincter muscle of the 
iris, which is commonly attended by paralysis of accom- 
modation, and may, or may not, be accompanied by 
paralysis of the other ocular muscles supplied by the 
third nerve. A widely dilated and immovable pupil, 
if glaucoma be excluded, points strongly to the influence 
of a mydriatic. Marked and persistent contraction of 
the pupil may be due to eserin or some other myotic, 
to opium poisoning, to disease of the brain and its 
meninges, causing irritation of the sphincter pupillae 
center, to spinal lesions, causing paralysis of the pupil- 
dilating center, or to paralysis of the cervical sympathe- 
tic. A dilated pupil which responds sluggishly or not 
at all to light, and is accompanied by impairment of 
vision for distant as well as near objects, glaucoma and 
adhesion of the iris to the lens capsule being excluded, 
indicates loss or impairment of function in the retina 
or optic nerve-tracts. 

It should be remarked, however, that in rare in- 
stances, when a lesion exists high up in the optic tract, 
beyond the point where the fibers which pass to the 
pupillary center are given off, the pupil may react to 



METHODS OF EXAMINING THE EYE. 2J 

light though absolute blindness be present. The 
opposite condition, in which the pupil fails to react 
to light though good vision exists, is frequently met with 
in the early stages of tabes dorsalis. When, under such 
circumstances, the reaction of the pupil to accommo- 
dation and convergence is retained we have what is 
known as the Argyll-Robertson symptom, due to a 
lesion involving the fibers, just mentioned, which pass 
from the optic tract to the center for pupillary move- 
ments. Usually the reflex immobility of the pupil met 
with in tabes dorsalis is associated with myosis, but 
exceptionally the pupil may be of normal size or even 
abnormally dilated. 

Determination of Acuteness of Vision. — To de- 
termine the visual acuteness for distant objects it is cus- 
tomary to employ capital letters of different sizes, which 
are printed upon a sheet of paper or upon cardboard. 
The test-letters suggested by Snellen (which are to be 
had of most opticians) are those commonly employed. 
The largest of Snellen's letters, designated by the 
Roman numeral CC, is of such size that it should be 
recognized by an eye having normal sight at two 
hundred feet. The letters next smaller should be dis- 
tinguished at one hundred feet, and finally there are 
letters recognizable at only fifteen feet, which is as 
small as is usually required for testing distant vision. 
If practicable, the letters, with a good light falling upon 
them, should be placed twenty feet from the patient; 
but whatever the distance it should be known, if the 
test is to be of even approximate accuracy. The sight 
of each eye should be determined separately, the other 
eye being "excluded" by holding a card or other 
opaque object before it. If at twenty feet the letters 
in the row marked XX, or if at fifteen feet those 



28 PREVALENT DISEASES OF THE EYE. 

marked XV, can be distinguished, vision (abbreviated 
"V") is practically normal, and is recorded thus: 
V = ~ or ^, as the case may be. If, however, 
at twenty feet only the letters which should be recog- 
nized at, let us say, fifty feet are distinguished, such a 
subnormal acuity of sight would be noted as V = -^-. 
Sometimes it will happen that not even the largest 
letter can be made out at the usual testing distance, 
and then it will be necessary to lessen the distance, 
until finally, at six feet, perhaps, it can be distinguished, 
when the record would be V = -—. 

When the impairment of vision is still more marked, 
the patient may be placed with his back to the light, and 
his ability to count fingers ascertained. In making this 
test the examiner holds up one hand, with the fingers sep- 
arated, and slowly approaches the patient until he can 
state correctly the number of fingers extended. If three 
feet should be the greatest distance at which he can do 
this, the record would be: "Fingers (or Fingers counted) 
at 3 feet." If he is unable at any distance to tell how 
many fingers are held up, we next try whether he can 
distinguish the movements of the hand by reflected 
light (his back being still to the source of illumination, 
usually a window). When even this is impossible, he 
may still have "light perception"; that is, he may be 
able, when facing the light, to tell when the hand is held 
in front of the eye and when it is removed. 

For testing near vision — ability to see at the usual 
reading or sewing distance — the test-types of Jaeger are 
commonly used. These consist simply of sentences 
printed in letters of different sizes, varying from No. I, 
"diamond" type, to No. 24, in which the letters are 
nearly an inch and three-fourths in height. The 
smallest type which the patient is able to read is as- 



METHODS OF EXAMINING THE EYE. 20, 

certained, and the result is noted as J. (or Jaeger) No. 
1, No. 6, No. 24, as the ease may be. In this test, as 
in the test for distant vision, the eyes should be ex- 
amined separately, and the patient should be seated 
with his back to the light. 

For testing accurately eccentric vision — determining 
the "field of vision" — a perimeter (Fig. 5) is required; 
but any considerable defect or contraction of the visual 
field may be detected in the following manner: Let the 
patient, with his back to the light, sit facing the ex- 
aminer, at a distance of about two feet, and, having 
closed one of his eyes, have him with the eye under 
examination look at the open eye of the examiner (who 
also should close one eye, the right if he is testing the 
patient's right eye and vice versa). Watching the 
patient to see that he does not change the direction of 
his gaze, the examiner now moves his hand from 
different parts of the periphery toward the center of 
the visual field, and in a plane about midway between 
his own and the patient's face. Using his own field of 
vision as a standard of comparison, and requiring the 
patient to tell the number of fingers he extends, and 
whether they are held still or moved, the examiner is 
able, in a few moments, to determine whether the 
eccentric vision of the patient is defective, whether, in 
any direction, his field of vision falls appreciably short 
of what it should be. By this method of examination 
such conditions as hemianopsia, the contraction of the 
field of vision characteristic of glaucoma, and that 
which occurs in detachment of the retina, in retinitis 
pigmentosa, etc., may be readily detected. 

In examining the eyes with a view to reaching a 
correct diagnosis it is of the first importance that the 
examination should be conducted in a systematic 



3° 



PREVALENT DISEASES OF THE EYE. 



©••• 




Fig. 5. — Standard registering perimeter. The examination may be 
made with the carrier which moves along the semicircle, or the test-object 
may be carried along this by means of dark discs attached to a long handle, 
each disc containing in its center the test-object. The patient's chin is 
placed in the curved chin -rest; the notched end of the upright bar is brought 
in contact with the face, directly beneath the eye to be examined, which 
attentively fixes the center of the semicircle. The other eye should be 
covered, preferably with a neatly-adjusted bandage. The record-chart 
is inserted at the back of the instrument, and by means of an ivory ver- 
nier the examiner is enabled to mark exactly with a pencil the point on the 
chart corresponding to the position on the semicircle at which the patient 
sees the test -object. The various marks are then joined by a continuous 
line, and a map of the field is obtained. 



METHODS OF EXAMINING THE EYE. 



31 



manner. Although the patient's account of his malady 
is, more often than not, indefinite and unsatisfactory 
and not infrequently misleading, it should be elicited 
at the outset; and if there is any reason to suspect that 
the eye affection is dependent upon a constitutional 
cause this too should be carefully inquired into. How 
long have the eye symptoms lasted is a most important 
question, which, if intelligently answered, will probably 
afford the examiner more assistance than any other 
one inquiry. Other important questions are, as to the 
existence of pain, photophobia, lacrimation, discharge 
(gumming of the lashes during sleep), and impairment 
of sight. In inquiring as to the last mentioned symp- 
tom it is essential that we should learn whether vision 
is defective for distant objects only, or for near objects 
only, or whether both are seen indistinctly, also whether 
diplopia exists. 

The answers to these questions should give, at least, 
a clue as to what to look for when the next step in the 
examination — the careful inspection of the eye bv day- 
light — is begun. The existence of pain, at all pro- 
nounced, for example, would suggest the probability of 
inflammation of the cornea, iris, or ciliary body being 
present, or, perhaps, glaucoma, or a foreign body or 
other traumatic lesion. Marked photophobia and 
lacrimation, usually coexistent with pain, have a like 
significance. Considerable muco-purulent or purulent 
discharge is indicative of inflammation of the conjunc- 
tiva, which, except in the more severe types, such as 
gonorrheal conjunctivitis, is not usually attended by 
pain, but rather by a sensation of irritation, as though 
"sand were in the eyes." Again, if the symptoms 
(impaired vision, irritability of the eyes, etc.) have 
lasted but a few days, one may put aside errors of 



32 PREVALENT DISEASES OF THE EYE. 

refraction and muscular anomalies, and search for a 
distinctly acute affection. A history of declining 
vision, without pain or external signs of inflammation, 
especially in a person beyond middle life, would point 
to cataract or, this being excluded, to disease of the 
retina or optic nerve. The existence of syphilis, 
nephritis, diabetes, alcoholism, or arteriosclerosis is 
especially significant in this connection. Photophobia, 
it should be remarked, is not, as might be supposed, 
a usual symptom of retinitis or neuritis. 

Epiphora of long standing suggests stricture of the 
lacrimal duct or canaliculi, or malposition or occlusion 
of the lacrimal puncta, and should lead to a careful 
examination of these structures. Poor vision for near 
objects, as in reading, with good distant vision, indi- 
cates failure or loss of the accommodative power of the 
eye, and in middle life usually means presbyopia; in 
childhood or early life, especially if occurring suddenly, 
paralysis of the ciliary muscles, as from diphtheria. 
A sudden onset of photophobia, lacrimation, and con- 
junctival injection, especially when limited to one eye, 
suggests the presence of a foreign body, which should 
be carefully looked for, even though the patient is not 
aware of its entrance. 

Long-continued discomfort in the eyes (asthenopia), 
usually more marked after near work, and which may 
or may not be accompanied by imperfect sight; head- 
aches, frontal or occipital, precipitated by reading, 
sewing or gazing fixedly at distant objects; chronic 
inflammation of the lid margins (blepharitis margina- 
lise-without other signs of constitutional disorder, and 
persistent hyperemia of the conjunctiva, indicate re- 
fractive errors, and less frequently muscular anomalies, 
and call for carefully adjusted glasses. If, under such 



METHODS OF EXAMINING THE EYE. $$ 

circumstances, there is good near vision and poor 
vision for distance, near-sightedness (myopia) probably 
exists; if both near and far vision are poor, hyperme- 
tropia of high grade or astigmatism. Ability to read 
ordinary print at the usual reading distance, it should 
be remarked, does not exclude myopia, but only myopia 
of high grade. Inability to obtain satisfactory 7 glasses 
at the usual presbyopic age (about forty-five) suggests 
difference in the refraction of the eyes, astigmatism or 
a muscular error. Diplopia of sudden onset, often 
but not always attended by an evident squint, is com- 
monly due to paralysis of one or more of the extrinsic 
eye muscles. Squint of long standing (rarely attended 
by diplopia), though it may have had its origin in an 
old paralysis, usually indicates the existence of a refrac- 
tive error of high grade. 

Although it seems almost incredible, it occasionally 
happens that the sight of one eve is lost, and monocular 
blindness exists for weeks or months, without the in- 
dividual being conscious of the fact. When, under such 
circumstances, the discovery is finally made, the ac- 
count usually given by the patient is that the loss of 
sight has only just occurred. The knowledge that such 
a thing is possible may prevent much perplexity in 
reaching a correct diagnosis. It is well, moreover, to 
bear in mind that, in general, the statements of patients 
as to the amount of sight they possess, particularly if 
the impairment of vision is limited to one eve, are often 
misleading. Influenced bv especial considerations, they 
may claim to have better vision than they really possess; 
but commonly they go to the other extreme, and des- 
cribe the loss of sight as being more complete than is 
actually the case. The patients themselves are often 
surprised to find their own convictions so much at 
3 



34 PREVALENT DISEASES OF THE EYE. 

fault; but occasionally it is evident that they are 
wilfully attempting to deceive the examiner. 

Inspection of the Eye by Daylight. — Guided by 
the information gained by the questions which have 
been enumerated, the examiner should next proceed to 
a careful inspection of the lids and the superficial 
structures of the eye. A single glance may, in some 
instances, suffice to confirm beyond doubt the tentative 
diagnosis already made, perhaps, as a result of these 
questions; but, at all events, the examination will 
seldom fail to afford distinctly helpful information. 

As a matter of routine, it will be well to glance at the 
lids, to see whether they are swollen, whether their 
position and movements are normal, their margins 
free from inflammation, and whether the eyelashes 
occupy their proper position and are neither deficient 
in number nor matted together by discharge. If 
there is a history of epiphora the position and pervious- 
ness of the lacrimal puncta should be observed, and 
pressure should be made upon the lacrimal sac; for 
if there is occlusion of the nasal duct there will almost 
surely be an accumulation of tears and mucus in the 
sac, and the pressure exerted by the finger will cause 
regurgitation through the lacrimal puncta. If for any 
reason it is desirable to inspect the inner surface of the 
lids — to search, for example, for a foreign body or to 
observe the condition of the palpebral conjunctiva — 
they should be everted in the manner already described. 

Next an examination of the eye itself should be made, 
and this should include a determination of the tension 
(T) of the ball, a careful inspection of the conjunctiva, 
with reference to injection and the presence of dis- 
charge, of the smoothness of the surface and the 
transparency of the cornea, of the color and appearance 



METHODS OF EXAMINING THE EYE. 35 

of the iris, of the size, shape, blackness, and reaction of 
the pupil, of the depth of the anterior chamber, and of 
the clearness of the aqueous humor. The movements 
of the eyes, binocular as well as monocular, should 
also be observed, especially if diplopia is complained 
of or strabismus is suspected. This may be done 
conveniently by means of a pencil, held fifteen inches 
from the eyes and moved in various directions, or a 
lighted candle at the distance of as many feet. The 
sensibility of the cornea, when glaucoma or paralysis 
of the ciliary nerves is suspected, should be determined 
by touching its surface lightly with a spill of tissue paper 
or absorbent cotton. 

The presence of marked opacity of the crystal- 
line lens, especially if the opacity involves the 
anterior cortical layers, may usually be detected by 
simple, daylight inspection; but if it is limited to 
the deeper cortical layers, to the nucleus, or to the 
periphery of the lens, or if the cataract, though fully 
formed, be amber-colored, it may easily escape de- 
tection. On the other hand, it should be remarked that, 
owing to the greater amount of light reflected by the 
crystalline lens in persons advanced in life, a mistaken 
impression that a cataract is present is often gained 
by mere daylight inspection, which is dispelled by a 
glance into the eye with the ophthalmoscope. 

When vascular injection of the eye is present much 
information may be gained by carefully noting the 
character of the hyperemia. A diffuse injection of the 
conjunctiva, least pronounced near the corneal limbus, 
of a brick-red color, the injected vessels being large, 
tortuous, and movable, is indicative of an inflammation 
limited to the conjunctiva. On the other hand, a zone 
of pericorneal injection, pinkish in color, composed of 



36 PREVALENT DISEASES OF THE EYE. 

fine, subconjunctival vessels, usually radiating from the 
corneal border, is of more serious import, and points to 
keratitis, iritis, cyclitis, inflammatory glaucoma or, per- 
haps, to the presence of a foreign body upon the cornea or 
beneath the upper lid. 

The character and amount of the discharge from 
the eye are also of diagnostic value. In the milder 
conjunctival inflammations the discharge is mucoid or 
muco-purulent in character and slight in amount, 
manifesting itself chiefly by gumming the lashes 
together during sleep; in the severer types of con- 
junctivitis, more especially in gonorrheal ophthalmia, 
it is very profuse and distinctly purulent, and a usual 
accompaniment is marked edema of the lids; in 
keratitis, iritis, and inflammatory glaucoma the dis- 
charge, due to excessive lacrimation, is watery, with 
but a slight admixture of mucus. It is a good rule in 
all inflammatory affections of the eyes, especially when 
met with in persons over forty years of age, to test the 
intraocular tension, or, in other words, to be on the 
lookout for glaucoma; for, as has been said already, 
no more unfortunate mistake can be made than to over- 
look the existence of this disease. 

Inspection of the Eye by Oblique Illumination. — 
Having completed the examination of the eye by 
daylight, if the diagnosis is still in doubt or further 
information bearing upon the treatment of the case is 
needed, the inspection of the eye by oblique illumina- 
tion, with or without the aid of a mydriatic, should next 
be undertaken. In the manner already described, by 
concentrating the light first upon one and then upon an- 
other of the superficial structures of the eye, the cornea, 
anterior chamber, aqueous humor, iris, and lens should 
be carefully scrutinized. In examining the cornea 



METHODS OF EXAMINING THE EYE. ^] 

one should look for disturbance of the epithelium, 
loss of substance, diminished transparency, superficial 
or deep, the deposition of exudates upon its inner 
surface, and the possible presence of a foreign body. 
In inspecting the anterior chamber one should consider 
its depth, the clearness of the aqueous humor, and the 
existence of hypopyon. The iris should be examined 
for alterations in color (as compared with the iris of the 
opposite eye), for swelling of its tissue, for inflammatory 
exudates, changes in position, and for the existence of 
anterior or posterior synechiae. We may also examine 
by this method the size and shape of the pupil, its re- 
action to light and its clearness. 

If we suspect iritis and the presence of posterior 
synechiae, but owing to the small size of the pupil are left 
in doubt, or if we wish to examine the lens for commenc- 
ing opacity, a mydriatic will afford the greatest possible 
assistance. A delay of, perhaps, fifteen minutes will be 
necessitated; but in the former case, if our suspicions 
are well founded, we shall obtain an irregularly dilated 
pupil, showing plainly the synechiae, and so putting the 
question of iritis beyond doubt; and in the latter, nearly 
the whole anterior surface of the lens will be exposed to 
view, and opacities will be readily detected, which before 
could not be seen. As has been pointed out, a mydri- 
atic transient in its effect, such as homatropin or 
euphthalmin, is best adapted for this purpose. 



CHAPTER II. 

GENERAL OBSERVATIONS UPON THE TREATMENT 
OF DISEASES OF THE EYE. 

In the management of eye diseases, a correct diag- 
nosis having been reached, the selection of the proper 
remedy to meet the condition is not usually a difficult 
matter, even for those who have not paid especial 
attention to this branch of medicine. This is so be- 
cause, in the first place, the indications are usually 
definite and clear and, in the next place, the list of 
available remedies is not a long one. 

In writing for the general practitioner there is, per- 
haps, less reason than there would be in addressing the 
specialist in ophthalmology to emphasize the fact that 
eye diseases should not be treated simply as local 
maladies, and that in their management constitutional 
remedies are at times even more important than local 
ones. There are, of course, diseases of the eye which 
are purely local affections, and which demand only 
local treatment; but there are many others which are 
but local manifestations of a constitutional disorder, 
and in which general measures, aimed at this disorder, 
are an essential part of their successful treatment. 

To enumerate all the drugs and therapeutic agents 
apt to be needed in treating the commoner diseases of 
the eye is not a difficult task, and the list need not be 
a long one. It would naturally be divided into local 
remedies and constitutional remedies. Such a list, 
fairly comprehensive, would be as follows : 

38 



GENERAL OBSERVATIONS UPON TREATMENT. 



39 



Zinc sulphate, 
Boracic acid, 
Mercury bichlorid, 
Sodium chlorid, 
Silver nitrate, 
Protargol, or 
Argyrol, 

Copper sulphate, 
Chlorin water, 
Carbolic acid, 
Salicylic acid, 
Yellow oxid of mercury 
Alum, 
Zinc oxid, 
Caustic potash, 
Mercurial ointment, 
Atropin sulphate, 
Eserin sulphate, 



LOCAL REMEDIES. 

Pilocarpin hydrochlorate, 

Holocain hydrochlorate, 

Hyoscyamin hydrobromate, 

Homatropin hydrobromate, or 

Euphthalmin hydrobromate, 

Cocain hydrochlorate, 

Adrenalin, 

Dionin, 

Tincture of iodin, 

Extract of opium, 

Extract of belladonna, 

Castor oil, 

Veratrin oleate, 

Jequirity, 

Cold (ice-cloths), 

Heat (dry or moist), 

Galvano-cautery, 

Local bloodletting (leeching). 



CONSTITUTIONAL REMEDIES. 
Mercury biniodid, Pilocarpin hydrochlorate, 



Mercury protoiodid, 
Mercury bichlorid, 
Calomel, 

Mercurial ointment, 
Potassium iodid, 
Quinin sulphate, 
Strychnin sulphate, 



Arsenic (Fowler's solution), 

Lithium, 

Colchicum, 

Cod-liver oil, 

Sodium pyrophosphate, 

Trional, 

Phenacetin, 



Extract or tincture of nux vomica, Diphtheria antitoxin, 

Iron phosphate, An energetic purgative (such as 

Iron iodid, the "compound calomel pow- 

Iron carbonate, der," mentioned in the ap- 

Opium, pendix). 

Morphin sulphate, 



Speaking broadly, it may be said, as to local remedies, 
that astringents and antiseptics are indicated when 
there is a considerable discharge from the eye of mucus 



40 PREVALENT DISEASES OF THE EYE. 

or pus, such discharge being indicative of inflammation 
of the conjunctiva. On the other hand, the existence 
of pain, photophobia, and lacrimation, symptoms 
characteristic of keratitis, iritis, etc., commonly con- 
traindicates their employment and calls for soothing 
remedies, especially atropin (unless there is -j- T of 
the eye) and opium. As the different varieties of in- 
flammation of the conjunctiva, if we except phlyctenular 
and diphtheritic conjunctivitis, are essentially local 
affections, it is evident that the field for astringents 
and antiseptics is mainly in local maladies. Atropin, 
on the other hand, while useful in certain purely local 
affections, as, for example, corneal ulcer due to direct in- 
fection, is more especially indicated in inflammations of 
the eye which have a constitutional origin, such as iritis, 
cyclitis, and phlyctenular, herpetic, and interstitial 
keratitis. 

In no department of medicine are an early diagnosis 
and a prompt employment of remedial measures more 
important than in ophthalmic practice. Especially is 
this true in the treatment of purulent (gonorrheal) con- 
junctivitis, of diphtheritic conjunctivitis, of iritis and 
of inflammatory glaucoma. In the first named affec- 
tion, and the observation applies as well to diphtheritic 
conjunctivitis, a delay of two or three days may mean 
loss of sight through necrosis of the cornea; in iritis 
it may mean a permanently damaged eye through the 
formation of unbreakable posterior synechias, while 
in the severer types of acute glaucoma a still briefer 
delay, of twenty-four or forty-eight hours, may result 
in absolute blindness from irreparable damage to the 
optic nerve and retina. 

Local Remedies. — Topical remedies for the eye 
are commonly in the shape of collyria — solutions in 



GENERAL OBSERVATIONS UPON TREATMENT. 41 

water of various drugs for instillation into the con- 
junctival sac ; lotions, to be applied on linen or 
gauze pads to the closed lids; ointments, for application 
to the eye itself or to the lids; powders, to be dusted 
into the eye, and crystals or crayons (copper sul- 
phate, alum, silver nitrate) for direct application to 
the eye, usually to the palpebral conjunctiva or to 
the lids. Strong antiseptic agents, such as pure car- 
bolic acid and tincture of iodin, are applied accu- 
rately and in small quantities to threatening corneal 
ulcers, and the actual cautery — the galvanocautery 
being best adapted to the purpose — is similarlv em- 
ployed. Heat and cold, the former in the shape of hot 
fomentations or drv heat (Japanese stove), the latter in 
the form of ice-cloths or small ice-bags, are also used. 
Ice-cloths, which are especiallv useful in gonorrheal 
ophthalmia, should be kept lying upon a block of ice,, 
from which they must be transferred at brief intervals 
to the lids of the affected eye. Moist heat may be 
conveniently applied by means of a soft, bird's-nest- 
shaped sponge, which should be kept at the desired 
temperature by being repeatedly dipped in hot water. 

For the application of collyria an eye-dropper is 
essential, and one with a bent nozzle is more convenient 
than a straight one (Fig. 6 and Fig. 7). As it is pos- 
sible to transfer infectious material from one eve to 
another by means of eye-droppers, certain precautions 
should be observed in their use. The danger of doing 
this is slight if the dropper is not allowed to come in 
contact with the lids or eye, which, of course, need not, 
and should not, happen. It is best, however, in the 
management of distinctly contagious diseases — such as 
gonorrheal conjunctivitis — that a special dropper should 
be set apart for each case, and this should not be used 



42 



PREVALENT DISEASES OF THE EYE. 



for another patient unless it has been sterilized by 
boiling. It is important also that a dropper which 




Fig. 6. — The right way to hold an eye-dropper. 




Fig. 7. — The wrong way to hold an eye-dropper. 

has been used for a mydriatic — atropin, for example — 
should not be used for the instillation of other collvria, 



GENERAL OBSERVATIONS UPON TREATMENT. 43 

as neglect of this precaution may result in a dilatation 
of the pupil and a blurring of vision that will cause the 
patient much needless inconvenience. 

As a rule, to apply more than one or two drops to 
the eye, as is often done, is unnecessary, since hardly 
that quantity is retained in the conjunctival sac, and 
in the case of poisonous solutions — atropin, hyoscyamin 
and the like — it is especially to be avoided, as general 
intoxication may be induced in this way. It is not 
uncommon for individuals to "taste" such medicines 
as those just mentioned shortly after their application 
to the eye, indicating that they have passed through 
the lacrimal passages and have reached the nose and 
pharynx. It is in this way that they impress the system, 
and for this reason it is better that poisonous collyria 
should be instilled near the outer, rather than near the 
inner, canthus. If it is desirable that the solution used 
should exert its full effect upon the cornea, as in kera- 
titis or iritis, the patient's head should be thrown back 
and he should be directed to look downward; the upper 
lid being then drawn up, it is easy to cause the drop to 
fall directly upon the exposed cornea. Under other 
circumstances it is more convenient to apply the drop 
between the lower lid and the eyeball, the patient 
looking upward and the lid being drawn slightly away 
from the ball (Fig. 8). 

Apothecaries have a reprehensible habit, in preparing 
solutions for the eye, of using a mortar and pestle to 
mix the ingredients indicated. This is wholly un- 
necessary, and nearly always results in contaminating 
the solution, as is shown in a few days by the appearance 
in it of a fungous growth. It is a practice which is 
without excuse, and which ought unquestionably to be 
abandoned. Equally deserving of condemnation, and 



44 



PREVALENT DISEASES OF THE EYE. 



for much the same reason, is the habit common 
among physicians of prescribing rose-water, instead 
of distilled water, as a solvent for drugs intended for 
application to the eye, because it has, or is supposed to 
have, a pleasant odor. There is a very general popular 
belief that collyria in order to be efficacious must be 




Fig. 8. — Convenient method of dropping solutions into the eye. 



"strong," must cause decided smarting when applied 
to the eye. It is scarcely necessary to say that this 
belief is without warrant. 

Such agents as protargol, strong solutions of silver 
nitrate, etc., which are commonly applied to the 
everted lids, can be applied most conveniently by means 



GENERAL OBSERVATIONS UPON TREATMENT. 45 

of a mop made by wrapping a little absorbent cotton 
around the sharp end of a wooden toothpick. Oint- 
ments may be applied to the inner surface of the upper 
or lower lid, the eye being directed downward in one 



Fig. 9. — Applying ointment to the eye with a wooden toothpick. 

case and upward in the other, with the broad, flat end 
of a toothpick (Fig. 9). If intended for application to 
the lids only, they may be rubbed on with the finger-tip. 
In preparing ointments for application to the eye 
vaselin or some similar preparation should be used 



46 PREVALENT DISEASES OF THE EYE. 

as a base, since it is advantageous that they should 
melt at the temperature of the body and so become 
diffused throughout the conjunctival sac; but when 
intended for application to the lids this is a disadvan- 
tage, and a firmer base, such as "vaselin cerate"* or 
cold-cream, should be used. 

Of all local remedies employed in the treatment of 
eye diseases, atropin is, perhaps, the most valuable. 
It is commonly prescribed in aqueous solution, the 
sulphate being used because it is freely soluble in water. 
Its value depends not only upon its efficacy in relieving 
pain and photophobia and favorably influencing in- 
flammation of various structures of the eye, but upon 
its action as a mydriatic, its mechanical effect in en- 
larging the pupil, which, as is well known, is of ines- 
timable value in the treatment of iritis. It is prescribed 
in solutions varying in strength from one-eighth of a 
grain to eight grains to the ounce, according to the 
effect desired. In iritis, and in other non-glaucoma- 
tous inflammations attended by pain, lacrimation and 
photophobia, a solution of the strength of four grains 
to the ounce (exceptionally, an eight-grain solution) 
is commonly employed. In inflammations in which 
these symptoms are not so marked, as, for example, 
the usual type of phlyctenular keratoconjunctivitis, 
a strength of one grain to the ounce generally suffices. 
The very weak solutions, the quarter-grain- or eighth- 
grain-to-the-ounce solutions, are used chiefly for their 
mydriatic effect, the former being applied once in three 
or four days to produce a continuous but not very 



* Composed of yellow wax, one part; vaselin, four parts. An oint- 
ment suggested by the author some years since. It is of suitable 
consistence, and will keep for a very long time without becoming 
rancid. 



GENERAL OBSERVATIONS UPON TREATMENT. \J 

marked mydriasis — to improve the vision, for example, 
in incipient cataract when the opacity is confined to 
the central portion of the lens; the latter, as a sub- 
stitute for the more evanescent mydriatics, when a 
transient dilatation of the pupil is needed to facilitate 
inspection of the lens or deeper eye structures. 

It is well to remember that the mydriasis produced 
by a strong solution of atropin — a four-grain solution — 
will frequently not disappear entirely for fifteen or six- 
teen days. It is inexcusable, therefore, to use such a 
solution when only a transient effect upon the pupil 
is desired. Euphthalmin is the most evanescent my- 
driatic that we possess, its effect lasting scarcely 
twenty-four hours; but it is a very expensive drug, 
and must be used in quite strong solutions — four to 
five per cent. — to insure the desired result. Homatro- 
pin is effective in much weaker solutions — two to four 
grains to the ounce — and, though its action upon the 
pupil is somewhat more prolonged, it is a very satis- 
factory agent to employ when only a brief mydriasis 
is desired. 

Although, as has just been said, atropin is so valu- 
able an agent, its use is attended with certain unfavor- 
able possibilities. In persons advanced in life it some- 
times precipitates an attack of glaucoma. Probably, 
this happens only when there exists a predisposition to 
this disease; but, at all events, it has led to caution in 
its use in old persons and an indisposition to prescribe 
it under such circumstances unless the need for it is 
clear. It is, doubtless, by dilating the pupil and crowd- 
ing the iris into the periphery of the anterior chamber, 
and thus clogging the lymph-passages in this region, 
that this unfortunate result is brought about. In 
penetrating wounds near the border of the cornea. 



48 PREVALENT DISEASES OF THE EYE. 

and in ulcers in this region which have perforated, or are 
about to perforate, into the anterior chamber, its em- 
ployment is contraindicated, since through its paralyz- 
ing effect upon the sphincter pupillae it favors the occur- 
rence of hernia of the iris. 

Again, the prolonged use of atropin may cause a con- 
junctivitis of follicular type, which is usually accompa- 
nied by annoying itching, and in persons peculiarly 
susceptible to the action of belladonna even a single 
application of an atropin solution to the eye may produce 
a conjunctivitis of this character, accompanied at times 
by marked edema and redness of the lids and face. 
Occasionally, too, when used in old persons, especially 
when both eyes are closed, as after operations for 
cataract, it causes delirium, which under such circum- 
stances may have serious consequences. Any one of 
the commonly employed mydriatics, it should be said, 
may produce the same unpleasant consequences as 
atropin, and the contraindications to their use are the 
same. Homatropin is the least poisonous, and, there- 
fore, is the least likely to cause delirium. A peculiar 
susceptibility to atropin, such as has been described, 
does not necessarily imply a like susceptibility to all 
the other mydriatics; so that when it is encountered 
some other member of the group — such as hyoscvamin, 
scopolamin, or duboisin — may, not infrequently, be 
substituted with good effect. 

As mydriatics tend to induce glaucoma by dilating 
the pupil and obstructing the nitration angle at the 
periphery of the anterior chamber, myotics (eserin 
and pilocarpin) tend to reduce increased intraocular 
tension, to control glaucoma, by contracting the pupil 
(which under such circumstances is almost always 
abnormally dilated), drawing the iris toward the center 



GENERAL OBSERVATIONS UPON TREATMENT. 49 

of the anterior chamber and freeing the lymph-spaces 
at its periphery. Such being the case, it is evident 
that we have in the behavior of the pupil a guide to 
the strength of the myotic solution required in the 
treatment of glaucoma. The stronger solutions of 
eserin, a much more energetic myotic than pilocarpin, 
through the vigorous contraction of the sphincter 
pupillae and the ciliary muscle which they induce, 
often cause pain in the eye, and when their use is 
long continued may even excite iritis. It is desira- 
ble, therefore, that they should not be used except 
when clearly demanded. In a word, the weak- 
est solution of eserin which will cause the pupil to 
contract, and will maintain it in a state of contraction 
(not excessive), is what one should aim to employ in 
endeavoring to control increased intraocular tension. 
In an acute attack of inflammatory glaucoma it often 
happens that even the strongest solution of eserin that 
we are in the habit of using (four grains to the ounce) 
will fail to overcome the dilatation of the pupil; but, 
on the other hand, in the intervals between the attacks, 
when it is used as a prophylactic, and in glaucoma 
simplex a strength of a quarter of a grain, or even an 
eighth of a grain, to the ounce usually suffices to ac- 
complish the desired result. In inflammatory glau- 
coma iridectomy, of course, is the sovereign remedy, 
and resort to it should not be unnecessarily delayed; 
but, if during an acute exacerbation eserin is to be used, 
a strong solution (four grains to the ounce) should 
be prescribed at once, without waiting to ascertain, 
whether a weaker solution will cause the pupil to 
contract. When, however, the conditions are not 
urgent, one should determine by trial the weakest solu- 
tion of eserin that will maintain the pupil in a state of 
4 



50 PREVALENT DISEASES OF THE EYE. 

moderate contraction when applied twice or, at most, 
three times a day, and direct this for future use. 

The prolonged use of a collyrium of eserin, which is 
commonly prescribed in the form of the sulphate, occa- 
sionally excites a follicular conjunctivitis very similar 
to that sometimes induced by atropin. When this 
happens, or when for any reason eserin is not well 
borne, the hydrochlorate of pilocarpin should be sub- 
stituted, and since its myotic action, as has been 
said, is much less powerful than that of eserin, it must 
be prescribed in considerably stronger solutions — in 
solutions of from one to eight grains to the ounce. 
The myotics, eserin especially, are distinctly contra- 
indicated in iritis, and if used through misapprehension 
of the true condition are sure to do harm, increasing 
the pain and aggravating the inflammation. 

Astringents and antiseptic agents, as has been 
pointed out, are especially indicated in the treatment 
of inflammations of the conjunctiva. In the milder 
types of conjunctivitis, such as the catarrhal and 
follicular varieties, they should be used in compara- 
tively weak solutions. Zinc sulphate, on the whole, 
is the most useful astringent, and boracic acid and 
bichlorid of mercury are the most useful antiseptics, 
in these conditions. The collyrium which I have 
found especially efficacious in catarrhal conjunctivitis 
is one containing half a grain of sulphate of zinc and 
ten to twelve grains of boracic acid to the ounce. 
Dropped into the eye freely, three times a day, it will 
seldom fail to cure an acute attack in a very few days. 
Bichlorid of mercury, which is useful more particularly 
in follicular conjunctivitis, in vernal catarrh, and in 
blennorrhea of the lacrimal passages, should be pre- 
scribed in solutions varying in strength from I : 12,000 



GENERAL OBSERVATIONS UPON TREATMENT. 51 

to I : 8000. The addition of sodium chlorid to 
the solution, in the proportion of three grains to the 
ounce (about the strength of normal salt solution), 
seems to add to its efficacy, and, moreover, renders 
it more acceptable to the eye. In asthenopia, in hyper- 
emia of the conjunctiva, in mild cases of catarrhal 
conjunctivitis, and, again, when one is uncertain as 
to the diagnosis, and wishes to prescribe something 
that will do a measure of good, at least, and will surely 
do no harm, boracic acid (10 to 12 grains to the ounce) 
is especially to be commended. In addition to its slight 
antiseptic and astringent action, it is decidedly soothing 
and grateful to irritable eyes. 

In the severer types of conjunctivitis, in purulent 
(gonorrheal) and trachomatous conjunctivitis, more 
energetic treatment is demanded, much stronger 
astringent and antiseptic solutions are called for, and 
in the first-named affection, especially, very much 
more assiduous attention. Silver nitrate in 2 per cent, 
solution or, preferably, protargol or argyrol in 20 to 40 
per cent, solution must here be employed. 

In applying tincture of iodin or pure carbolic acid 
to corneal ulcers, the application may be conveniently 
made by means of a sharply pointed wooden toothpick, 
about the tip of which a very little absorbent cotton 
— a few fibers only — has been wound. To prevent 
the cornea being acted upon more extensively than 
is desired the improvised applicator should carry only 
a very small quantity of the fluid. 

Cocain may be used with good effect to do away 
with the pain caused by the application to the eye of 
such severe remedies as silver nitrate, copper sulphate, 
carbolic acid, iodin, etc.; but as a remedial agent per 
se, apart from its use as a local anesthetic, it should 



52 PREVALENT DISEASES OF THE EYE. 

never, in my judgment, be employed. For not 
only is the relief which it affords — from pain, pho- 
tophobia, etc. — very evanescent, but it markedly dis- 
turbs the nutrition of the cornea, causes, not infre- 
quently, desquamation of the corneal epithelium, and 
brings about a condition peculiarly favorable to the 
invasion of pathogenic bacteria. From time to time 
cases of inflammation of the superficial structures of 
the eye have come under my observation in which 
cocain had been used, and in which its ill effects were 
plainly manifest. 

Dionin, one of the more recent additions to the 
pharmacopoeia of the ophthalmologist, owes its value 
to its action as an analgesic and a lymphagogue. It is 
useful in iritis, not only because of its analgesic effect, 
but because it increases the mydriatic action of the 
atropin, in association with which it is employed. 
In inflammatory glaucoma it tends to reduce the 
intraocular tension, as well as to relieve pain. It is 
beneficial also in keratitis, more especially in paren- 
chymatous keratitis, and through its action as a lymph- 
agogue it promotes the absorption of recent corneal 
opacities and the remnants of cortical lens substance 
left after operations for cataract. It is used commonly 
in five per cent, solution, and in this strength may be 
applied to the eye twice to four times daily. The 
immediate effect of its application is to cause con- 
siderable irritation, not infrequently decided pain, 
and pronounced edema and congestion of the conjunc- 
tiva. The analgesia which supervenes in fifteen or 
twenty minutes lasts for some hours. A tolerance to 
dionin is established usually after it has been used a few 
days, and after this its further employment is of doubt- 
ful value. 



GENERAL OBSERVATIONS UPON TREATMENT. 53 

The use of opium as a local application in eye dis- 
eases, formerly much in vogue, does not receive at the 
present day the attention it deserves. I am not in- 
clined to employ it as a collyrium — for application to 
the eye itself; but, as a lotion to be applied by means 
of a gauze or linen pad to the closed lids, I have found 
it a most useful remedy in all painful inflammations 
of the eye, and especially in those of traumatic origin. 
It should be prescribed in the strength of from ten to 
fifteen grains of the extract of opium to four ounces 
of distilled water, to which it is often advantageous 
to add from forty to sixty grains of boracic acid. When 
its action is favorable, it can hardly be applied too 
persistently, though it is well to remember that in sus- 
ceptible individuals opium used in this way occasion- 
ally produces its characteristic constitutional effect. 
As a rule, it should be applied at the temperature of 
the atmosphere, but occasionally it affords greater 
relief when used as hot as can be conveniently borne. 
A gauze pad of suitable thickness, wet with a saturated 
solution of boracic acid or with the lotion of opium 
and boracic acid just mentioned, and covered with a 
piece of rubber protective or oiled silk or muslin, makes 
an excellent "poultice," and one which is much more 
cleanly and convenient of application than the poultices 
of flaxseed-meal, etc., which are commonly employed. 

Ointments are applied to the lids to prevent their 
becoming stuck together by the drying of discharge 
upon the eyelashes, as in the different types of conjunc- 
tivitis, and to cure inflammation of the lids or their 
margins (blepharitis marginalis). For the purpose 
first named a simple, bland ointment, such as cold- 
cream, to which boracic acid may be added (five 
grains to the dram), is best adapted. For blepharitis 



54 PREVALENT DISEASES OF THE EYE. 

marginalis nothing is so generally efficacious as the 
so-called "yellow salve" (yellow oxid of mercury, 2 
grains; cold-cream or "vaselin cerate," 1 dram). 
An ointment of salicylic acid of the same strength is 
also useful in this condition, as well as in eczema 
involving the lids or neighboring parts. 

In burns of the eye, whether from hot substances 
or caustic agents, and in abrasions of the cornea, castor 
oil is a useful application, affording, as it does, a pro- 
tective covering to the inflamed surfaces. A still more 
soothing application under such circumstances is a 
solution of atropin (the alkaloid, not the sulphate) 
in castor oil (four to eight grains to the ounce). 

Light, in so far as its influence upon eyes which are 
the seat of pathological changes is concerned, is not 
the reprehensible thing it was once supposed to be, 
and the confinement of patients with ocular inflamma- 
tions in quite dark rooms, as well, as the closure of 
the eyes by thick bandages designed to exclude light, 
very generally practised in former days, is now regarded 
not only as uncalled for but as actually harmful in 
many conditions. The misadventures, especially those 
occurring after important operations upon the eye, 
formerly attributed to premature or undue exposure 
of the eyes to light, are now known to be caused — in 
the great majority of instances, at all events — by bac- 
terial infection, against which, at the present day, we 
guard with greater assiduity than we display in trying to 
avoid the supposed ill effects of light. 

In saying this, however, I do not wish to be under- 
stood as holding that inflamed and painful eyes should 
not be protected from undue exposure to light; for, 
as a rule, it is desirable, unquestionably, that they 
should be. An eye in which there exists inflammation 



GENERAL OBSERVATIONS UPON TREATMENT. 



55 



of the iris, of the ciliary body, or the cornea, or which 
is the seat of an attack of acute glaucoma, will cer- 
tainly be made more photophobic and painful and, 
perhaps, actually worse, so far as the inflammatory 
condition is concerned, by undue exposure to light, 
and this should, without doubt, be avoided; but this 
does not mean that the patient must be shut up in 
an absolutely dark room, or that his eyes must be 




Hmp* 



s -^u 



Fig. 10. — Author's bandage, as applied to one eye. 

confined by, and subjected to the poultice-like action 
of, a roller bandage of many thicknesses. It means 
simply that he should avoid very light rooms, and that 
he should wear smoke-tinted (but not too darkly 
tinted) spectacles (coquilles), which may be supple- 
mented by a monocular or a binocular eye-shade or 
a piece of black court-plaster attached to the glass 
which covers the affected eye, if photophobia be a 
marked symptom of the attack. 



56 



PREVALENT DISEASES OF THE EYE. 



Bandages are seldom necessary except after certain 
operations, or after serious injuries of the eye, or for 
the purpose of holding in position pads used for the 
application of lotions to the lids; and for these pur- 
poses a light, easily applied and easily removed bandage, 
such as that contrived some years ago by the author* 
(Figs. 10 and 1 1), is greatly to be preferred to the clumsy 




Author's bandage, as applied to both eyes. 



* This bandage, which can be used for one or for both eyes, 
as shown in the illustrations, consists of a head-piece, to which 
the tapes are attached, and ah eye-piece with a buttonhole at 
each end, through which the tapes are passed. The head-piece 
consists of two straight strips of cotton cloth, of good quality, 
twelve inches long and one inch and three-quarters wide, the 
ends of which are sewed together so that the strips shall form 
a right angle. The eye-piece, made of the same material cut bias, 
when intended for one eye, is of oval shape, six inches and a half 
long by two inches and three-quarters wide at its widest part; when 
intended for closing both eyes, it is rectangular, and should be 
seven inches and a half in length by two inches and three-quarters 
in width. The size of the head-piece may be varied, to fit small 
or large heads, by cutting the strips a half-inch shorter or longer. 



GENERAL OBSERVATIONS UPON TREATMENT. 57 

roller bandage, which, however, many ophthalmic sur- 
geons employ even at the present day. 

It is hardly necessary to say that inflamed and 
painful eyes should be given complete rest from such 
work as reading, writing, sewing, and the like; but it 
may be well to point out that this is as true when only 
one eye is affected as it is when both are involved, 
since it is almost as trying to the inflamed eye to have 
its fellow taxed as it is to be taxed itself. 

It is often extremely difficult to examine, or to make 
applications to, the eyes of unruly children. When 
this difficulty is met with, it may be easily overcome 
in the following manner: Let the child be placed across 
the lap of an attendant or nurse, who is instructed to 
hold its hands firmly. Then let the phvsician, seating 
himself in a convenient position for the purpose, and 
having thrown a towel over his lap, take the child's 
head between his knees. In this way he is enabled to 
hold it very securely, while, both his hands being free, 
it is not difficult for him to separate the lids in order 
to inspect the eye, or to make such applications as 
may be needed. 

Constitutional Remedies. — As is indicated by the 
briefness of the list given in the early part of this 
chapter, the number of constitutional remedies required 
in the treatment of diseases of the eye is small. 

Since syphilis plays a very important role in the eti- 
ology of eye diseases, the antisyphilitic drugs — mercury 
and potassium iodid — are among the most useful 
remedial agents employed in ophthalmic practice; but 
their value, it should be said, is not limited to diseases 
of syphilitic origin only. On the contrary, they are 
of great value in all ocular inflammations in which 
there is a tendency to plastic exudation and proliferation 



58 PREVALENT DISEASES OF THE EYE. 

of connective tissue. This is especially true of inflam- 
mations of the uveal coat (iris, ciliary body, and cho- 
roid), of the retina and optic nerve, and of the motor 
nerves which supply the extrinsic eye muscles. On 
the other hand, a tendency to purulent infiltration, 
to ulceration and necrosis, especially of the cornea, 
is a distinct contraindication to their use. 

When it is important to bring the system promptly 
under the influence of mercury, as in syphilitic iritis 
or irido-choroiditis of severe type, we can not do better 
than to administer calomel in small, frequently re- 
peated doses, — half a grain every hour or every two 
hours, — guarded, if need be, by small doses of opium. 
Inunctions of mercurial ointment may supplement 
the calomel, if thought desirable. When the purpose 
of the inunctions is to impress the system, they should 
be made, in the usual way, to the inside of the thighs 
and arms. With less effect upon the system, a decided 
impression may be made upon the eyes by applying 
mercurial ointment several times daily to the forehead 
and temples. In iritis and cyclitis the addition of ex- 
tract of belladonna to the mercurial ointment, in the 
proportion of one dram to the ounce, renders this 
procedure still more efficacious. 

When less urgency is demanded, one of the best 
ways of administering mercury in diseases of the eye 
is in the form of the biniodid, which may be given in 
solution (with the addition of a few grains of potas- 
sium iodid) or in tablet-triturates, and in doses varying 
from a sixteenth to a thirty-second of a grain, three 
times a day. When the exhibition of iron as well as 
of mercury is indicated, as is frequently the case in 
ocular affections dependent upon inherited syphilis, 
the syrup of the iodid of iron may be added, in such 



GENERAL OBSERVATIONS UPON TREATMENT. 59 

proportion as desired, to the biniodid solution, or, if 
the iodids are not well borne, the bichlorid of mercury 
in solution, with the addition of the tincture of chlorid 
of iron, may be given instead. 

Potassium iodid, in order to secure the best results 
in the ocular maladies in which it is indicated, must 
often be given in liberal doses. This is especially true 
of the diseases of the eye occurring in the tertiary 
stage of syphilis, of the disturbances of sight, whether 
strictly visual or motor, arising from intracranial af- 
fections, of the so-called neuropathic inflammations 
of the eye, and of that obscure and frequently intractable 
disease, serous iritis, or, as it is more correctly de- 
nominated, general uveitis. When it is to be admin- 
istered in increasing doses, it is convenient to prescribe 
it in saturated solution, so that each drop shall repre- 
sent a grain of the iodid. It is frequently given, with 
good effect, in combination with the biniodid or bi- 
chlorid of mercury. 

The salicylates, sodium and lithium, are remedies 
of much value, not only in rheumatic affections of the 
eye (which comprise a not insignificant group), but 
also in traumatic and post-operative inflammations, 
and even in iritis and iridocyclitis of syphilitic origin. 
The lithium salt is supposed to have a somewhat less 
disturbing effect upon the stomach. The dose of each 
is the same — ten to twenty grains — every three hours. 
When they — and this is true also of potassium iodid — 
are not well borne by the stomach, two teaspoonfuls of 
Fairchild's essence of pepsin given with each dose will 
often obviate completely this difficulty. 

In suppuration, ulceration and necrosis of the 
cornea — the conditions which, as has been said, espe- 
cially contraindicate the administration of mercury 



60 PREVALENT DISEASES OF THE EYE. 

and to a less degree that of potassium iodid — quinin 
is of undoubted value, and should be given in such 
doses as to produce cinchonism. It is also extremely 
useful, especially in combination with iron and strych- 
nin or nux vomica, in those affections of the eye 
which are dependent upon an impaired state of the 
general health, such as phlyctenular conjunctivitis or 
keratitis, blepharitis marginalis, eczema of the lids, 
etc. A favorite combination with me in such cases 
is the elixir of the phosphates of iron, quinin, and 
strychnin, preference being given to the elixir prepared 
by Wyeth and Bro., since it contains, besides a sixtieth 
of a grain of strychnin, two grains of iron and one 
grain of quinin to the dram — more than twice as much 
of the two last-named ingredients as do many of the 
preparations which are called by the same name. The 
syrup of the iodid of iron, which is more often admin- 
istered in these affections, is useful when they are 
associated with a distinctly strumous diathesis, mani- 
fested by enlarged lymphatic glands, etc.; but, except 
under such circumstances, the iron, quinin, and strych- 
nin combination just mentioned has afforded me de- 
cidedly better results, and I have no hesitation in 
strongly commending it. 

Strychnin, in gradually increasing doses, given by 
the mouth and not, as some (absurdly, I think) recom- 
mend, by hypodermic injection, and usually in con- 
nection with potassium iodid, is valuable in ambly- 
opic affections, and in paralyses of the ocular muscles 
of not too long standing. Opium and morphin are 
chiefly useful for the relief of pain, in such diseases as 
iritis, cyclitis, and inflammatory glaucoma. Sulphonal 
and trional I have found especially useful in giving 
quiet sleep and relief from nervousness after important 



GENERAL OBSERVATIONS UPON TREATMENT. 6l 

operations upon the eye, and, as a matter of routine, 
I prescribe one or the other of these drugs, to be given 
several hours before bedtime, after cataract extractions, 
iridectomies, etc. 

There can be no question as to the value of an 
energetic cathartic, particularly one containing a liberal 
proportion of calomel, in many inflammatory affections 
of the eye, and especially in iritis, in acute glaucoma, 
and in phlvctenular keratoconjunctivitis, accompa- 
nied, as it so often is, by eczema of the lids and face 
and by nasal catarrh. In the last-named condition 
the good which it accomplishes so promptly seems, 
in great measure, to be due to its action in ridding 
the alimentary canal of bacteria and their toxins, or, 
as the older writers used to express it, in "Cleaning 
out the primcB vice." 

Pilocarpin, which, like strychnin, may be given 
by the mouth with good effect and without incon- 
venience, and which, therefore, should not be admin- 
istered hypodermically, is useful at times in retinitis, 
in choroiditis, and in detachment of the retina. Col- 
chicum and lithium (lithia water or the citrate or 
carbonate of lithium tablets) are indicated in gouty 
inflammations of the eye (iritis, retinitis, scleritis, and 
chronic conjunctivitis), and arsenic, generally in the 
form of Fowler's solution, in the different varieties 
of herpes. 

The diphtheria antitoxin, as reported by trust- 
worthy observers, has proved so eminently efficacious 
in controlling diphtheritic conjunctivitis — a disease 
hitherto regarded as one of the most dangerous to 
which the eye is liable — as to have completely over- 
shadowed all local measures. It should be adminis- 
tered as in diphtheria affecting the fauces. 



62 PREVALENT DISEASES OF THE EYE. 

In acute suppurative processes involving the lids, 
the lacrimal sac, or the orbit, sodium pyrophosphate, 
in liberal doses, is of undoubted value. For an adult 
the dose is twenty grains every two hours; for a child, 
from ten to fifteen grains every two or three hours. It 
should be prescribed in solution, and, as it is not 
very soluble, as much as half an ounce of water should 
be allowed for each twenty grains of the salt. 



CHAPTER III. 
DISEASES OF THE EYELIDS AND ORBIT. 

DISEASES OF THE EYELIDS. 

Diseases of the eyelids are of common occurrence 
and, as a rule, may be dealt with satisfactorily by the 
general practitioner. Usually, they require local treat- 
ment only, but this is not always the case. 

Blepharitis Marginalis. — Inflammation of the lid- 




Fig. 12. — Blepharitis marginalis (Haab). 

margin, or blepharitis marginalis (Fig. 12), a condition 
not infrequently met with in both children and adults, 
is characterized by redness of the edges of the lids, 
the formation of crusts upon them, and, in severe and 
protracted cases, by more or less complete loss of the 
eyelashes. Because the inflammation is not limited 
to the surface of the lid, but involves as well the hair- 
follicles and accompanying sebaceous glands, it is some- 
times called blepharo-adenitis. In severe cases ulcera- 

63 



64 PREVALENT DISEASES OF THE EYE. 

tion occurs about the orifices of the follicles (Fig. 13); 
it is usually superficial, however, and the loss of tissue 
is slight. It is commonly a chronic condition, and, 
unless its etiology is understood and the treatment 
regulated with reference thereto, it is apt to be an 
intractable one. In children, it is usually due to mal- 
nutrition and a consequent depraved state of the sys- 
tem, and under such circumstances it is often accom- 
panied by eczema of the face or ears or by phlyctenular 
conjunctivitis. In adults, it arises exceptionally, espe- 




Fig. 13. — The palpebral aperture ; the lid margin somewhat everted, so 
as to show the openings of the ducts of the meibomian glands, d, e, the fol- 
licles of the cilia (the lashes having been removed), b. c, and the lacrimal 
pun eta, /, g (Nunneley). 

cially in strumous subjects, from a like cause; but 
much more frequently it is produced by accommodative 
strain, that is to say, is dependent upon an error of 
refraction, such, for example, as hypermetropia or 
astigmatism. The severe cases, attended by ulceration, 
destruction of the hair-follicles, and permanent loss 
of the eyelashes, are seldom met with except in the 
strumous variety of the disease. Those cases which 
have their origin in accommodative strain, though 
prone to chronicity, are not of this severe type. 



DISEASES OF THE EYELIDS AND ORBIT. 65 

Exceptionally, blepharitis marginalis is dependent 
upon lacrimal disease — when it is apt to be unilateral — 
or upon chronic rhinitis. It occurs also in connection 
with acne rosacea, but then the inflammation usually 
is not confined to the lid-margin. 

Treatment. — The treatment of blepharitis marginalis, 
when regard is had to the underlying cause which has 
given rise to it, generally yields most gratifying results; 
on the other hand, if this is not taken into account, the 
outcome is likely to be far from satisfactory. Speaking 
broadly, it may be said that when a case of chronic 
blepharitis marginalis is encountered in an adult or 
in a child old enough to attend school, without other 
signs of constitutional disorder, the presumption is 
warranted that an error of refraction, or possibly an 
anomaly of the ocular muscles, exists, and it may be 
added that the cure of the lid affection will necessarily 
involve the adjustment of suitable glasses. On the 
other hand, when the disease is met with in young 
children, especially in association with facial eczema or 
phlyctenular conjunctivitis, remedial measures having 
reference to the disordered state of the system are of 
the first importance, and this is true also of those cases 
which occur in strumous adults. 

The most useful local remedy in all varieties of 
blepharitis is the yellow oxid of mercury. It should 
be used in the form of an ointment, of the strength 
of two grains to the dram (hydrarg. ox. flav., gr. viij; 
ung. aquae rosae vel "vaselin cerat.," 5ss). A single 
application in twenty-four hours usually suffices, the 
best time for this being just before going to bed. 
Before each application the margins of the lids should 
be carefully freed of all crusts by persistent bathing 
with warm water, a bit of soft sponge or rag being 
5 



66 PREVALENT DISEASES OF THE EYE. 

used to facilitate the detachment of the scabs, and all 
loose eyelashes should be removed by gentle traction 
with the thumb and finger. The efficacy of the treat- 
ment depends, in no small degree, upon the thorough- 
ness with which this preliminary cleansing is done. 
In the rare instances in which the "yellow oxid" oint- 
ment does not act favorably, one may employ instead, 
and in the same manner, an ointment of salicylic 
acid (gr. j-ij to 5j). 

In obstinate cases, and especially in those of severe 
type, attended by ulceration, much benefit results 
from touching lightly the margins of the lids (previ- 
ously freed of crusts) with a pointed crayon of silver 
nitrate. In doing this care should be exercised to 
prevent the silver salt from coming in contact with 
the conjunctival surface of the lid, otherwise consider- 
able irritation of the eye will result. 

When the blepharitis is dependent upon a disordered 
state of the system, and especially when it is accom- 
panied by eczema of the face, phlyctenular conjunc- 
tivitis or otorrhea, as a step preliminary to the tonic 
treatment which is indicated, the bowels should 
be moved freely by one or more doses of calomel, 
scammony, and rhubarb, an excellent purgative com- 
bination, which will, hereafter, be spoken of as "com- 
pound calomel powder," the formula for the same 
being given under this name in the "Appendix." 

The good effects of this "unloading of the prima? 
viae," as the older writers used to express it, are, as a 
rule, promptly manifested, and it will sometimes happen 
that the case is well on the way to recovery before 
other treatment (apart from the yellow oxid ointment, 
which should be prescribed when the purgative is 
ordered) is begun. The most useful tonic in these 



DISEASES OF THE EYELIDS AND ORBIT. 6j 

cases is a combination of the phosphates of iron, 
quinin, and strychnin.* Exceptionally, in distinctly 
strumous subjects, exhibiting enlarged lymphatic glands, 
etc., the syrup of the iodid of iron or one of the cod- 
liver oil emulsions may answer a better purpose. 

From what has been said regarding the frequent 
dependence of blepharitis upon errors of refraction, 
it is obviously the duty of the physician when he meets 
with an intractable case of this affection,- to direct the 
patient, without unnecessary delay, to a competent 
specialist, in order that the glasses, which it is probable 
are urgently demanded, may be prescribed. 

Hordeolum (Stye). — Styes are of such common 
occurrence that every physician is familiar with their 
appearance. Very considerable diffuse edema of the 
lid commonly marks the incipient stage of a stye. 
Presently, at some point near the lid-margin a more 
defined swelling, attended by redness and tenderness, 
makes its appearance. Within a day or two suppura- 
tion takes place at this point, the overlying tissue 
softens, and there occurs a slight discharge of thickish 
pus. The pain, perhaps quite severe, which has been 
experienced up to this time now quickly subsides, 
and here the trouble may end. However, so fortunate 
an outcome as this is rather exceptional, for styes are, 
so to speak, gregarious, and when one has made its 
appearance others are apt to follow. The explanation of 
this is not far to seek, when we consider their etiology. 
Almost invariably styes, which are simply furuncles 
occurring in the lids, have their starting-point in some 
one of the numerous glands with which the eyelids 

* The elixir of the phosphates of iron, quinin and strychnin pre- 
pared by Wyeth and Bro. and a syrup of about the same strength 
made by Sharp and Dohme are especially to be commended. 



68 



PREVALENT DISEASES OF THE EYE. 



are so plentifully supplied (Fig. 14). The conditions 
being such as to favor its development, the Staphylococ- 







b' f 



Fig. 14. — Vertical section through the upper eyelid (Waldeyer) : 
a, Skin; b, cut fibers of the orbicularis; b', ciliary bundle of orbicularis; 
c, muscle (involuntary) of Miiller; d, conjunctiva; e, tarsal plate in which 
are embedded the meibomian glands (/) ; g, sebaceous glands near cilia 
(h); i, small hairs of integument; ;', sweat-glands; k, posterior tarsal glands. 

cus aureus, or some other pvogenic organism, invades 
one of the meibomian, or one of the sebaceous, glands 
or the follicle of an eyelash, and the inflammatory pro- 



DISEASES OF THE EYELIDS AND ORBIT. 69 

cess is started. Suppuration once established, the infec- 
tion of other glands is almost sure to occur, and so it 
happens that a sequence of styes is the rule rather 
than the exception. 

The existence of blepharitis marginalis is the most 
common predisposing cause of styes. Accommodative 
strain is another predisposing cause; for, even when it 
does not excite an actual blepharitis, it is apt to induce 
a hyperemic condition of the lids which favors furun- 
culosis. A "run-down" state of the system also may 
be a cause of styes, as it may be of furuncles in other 
regions. Habitual constipation is still another predis- 
posing cause. 

Treatment. — Prophylactic: Whether blepharitis be 
present or not, the history of repeated attacks of styes 
should suggest the probable existence of accommo- 
dative strain. Therefore, in all such cases a careful 
test of the refraction should be made. If blepharitis 
exists, the yellow oxid ointment should be prescribed 
and should be used systematically. This ointment is 
also useful, since it lessens the danger of secondary 
infections, in preventing the recurrence of styes. For 
overcoming habitual constipation aloin, in doses of 
a tenth to a fifth of a grain, at bedtime, is especially 
efficacious. 

Abortive : If a stye is seen in its incipiency, it is 
usually possible to prevent its development. One way 
of doing this is to apply a strong solution of sulphate 
of zinc (gr. xxx to gj) to the external surface of the 
eyelid, over the sensitive region where it is evident 
the stye is about to form. To be effectual the applica- 
tions must be frequently repeated — at intervals of half 
an hour throughout the day. The solution may be 
applied with the tip of the finger, care being exercised 



JO PREVALENT DISEASES OF THE EYE. 

to prevent its flowing into the eye, as this would cause 
considerable irritation. A few fibers of absorbent 
cotton placed over the region of the stye will adhere to 
the surface of the lid after having been once wet, and, 
by holding a greater quantity of the solution in contact 
with it, will make the application more efficacious. 

Another method of aborting a stye is to introduce 
a minute quantity of pure carbolic acid into the in- 
fected follicle. A careful inspection of the margin of 
the lid will frequently show which follicle is involved, 
for the orifice of the infected follicle will be either 
slightly swollen and congested or there will be a little 
discharge oozing from it. When this has been determ- 
ined, a wooden toothpick, made quite slender and sharp- 
pointed, should be dipped into carbolic acid and insinu- 
ated, as far as practicable, into the follicle. One should, 
of course, be careful to prevent the acid coming in 
contact with the eve; but this is not likely to happen 
if the toothpick is slender, and the precaution is taken 
to shake off any excess of the acid from its tip. This 
procedure is usually effectual, if resort to it is not 
too long delayed. 

When it is evident that abortive treatment is not 
likely to be successful, the suppurative process should 
be hastened by the application of poultices or hot 
fomentations, and as soon as pus has formed it should 
be evacuated by an incision made, with a keen-edged 
and sharp-pointed knife, parallel to the border of the 
lid. For this purpose the old-fashioned, triangular 
cataract knife or a Graefe cataract knife is well adapted. 
As soon as the pain and discharge have abated the 
poultices should be discontinued, and the ointment of 
yellow oxid of mercury (gr. ij to "vaselin cerate" 5j) 
should be used instead. This will not only tend to 



DISEASES OF THE EYELIDS AND ORBIT. JI 

dissipate the remaining inflammation and induration; 
but, as has already been said, will, perhaps, prevent 
the development of other styes. When the system 
needs building up the tonics likely to prove most useful 
are the tincture of chlorid of iron, the elixir of phos- 
phates of iron, quinin, and strychnin (as recommended 
in blepharitis), and the well-known combination of 
quinin, carbonate of iron, and nux vomica, which may 
be given conveniently in capsules or in pills. When 
a purgative is indicated, which is not infrequently the 
case, the "compound calomel powder" will be found 
to answer an excellent purpose. 

Eczema. — Eczema of the eyelids is commonly 
associated with eczema upon other parts of the face; 
it is also a not infrequent accompaniment of phlyctenu- 
lar ophthalmia (Fig. 15). Epiphora, due to malposition 
of the lacrimal puncta or to stricture of the nasal duct, 
often causes an eczema of the lower lid and occasionally 
of the cheek, the skin being irritated by the constant 
overflow of tears and mucus. Eczema limited to the 
inner canthus, and less often to the outer canthus, is not 
uncommon. " When occurring in the former position, 
it is usually dependent upon inflammation of the lac- 
rimal passages or upon chronic rhinitis. In children 
eczema, like phlyctenular conjunctivitis, is often due to 
faulty digestion consequent upon improper food and 
unsanitary surroundings; in adults it may be dependent 
upon a gouty diathesis. 

Treatment. — The ointments of yellow oxid of mer- 
cury and of salicylic acid, as recommended in blephar- 
itis marginalis, are the most useful local remedies. 
Another useful application is an ointment of oxid of 
zinc and boracic acid (zinci oxid., gr. ij; acid, boracic, 
gr. iv; ung. aquae rosae, 5j). If the eczema is caused 



72 



PREVALENT DISEASES OF THE EYE. 



by epiphora, this must be remedied. If the overflow 
of tears is due to malposition (usually eversion) of the 
puncta, the lower canaliculus must be slit; if dependent 
upon occlusion of the lacrimal duct, this must be over- 
come by the systematic use of probes, as described in 
the succeeding chapter. 

The condition of the general health should also be 




Fig. 15. — Eczema of the lids and face, with associated phlyctenular con- 
junctivitis (Haab). 



looked to — the bowels should be opened, the diet 
regulated and suitable tonics administered. When 
gout is present, the natural lithia waters will be found 
beneficial. Especially when the eczema is limited to 
the margin of the lids, and has existed for a consider- 
able time, accommodative strain should be suspected, 
and the refractive condition of the eyes should be 
looked into. 



PLATE I. 







t^oh+Xl' 



Ho*- 



Chalazion of the Upper Lid. 



DISEASES OF THE EYELIDS AND ORBIT. 



73 



Chalazion (Tarsal Cyst). — An acute inflammation 
of a meibomian gland, ending in suppuration, consti- 
tutes, as has been said, one variety of stye. A chronic 
inflammation of one of these glands, or an inflammation 
which, though acute at the outset, does not go on to 
suppuration, frequently leads to the development of 
a chalazion or tarsal cyst. A chalazion, after slowly 
increasing in size for some weeks, or even for several 
months, until it becomes, perhaps, larger than a large 




Fig. 16. — Vertical section of chalazion (meibomian cyst); X io> 
glycerin: i, Stratified epithelium continued over the surface; 2, connec- 
tive-tissue outside tumor; 3, capsule of fibrous tissue from which septa 
pass inward, dividing the cyst into lobules; 4, epithelial cells inside capsule; 
5, fatty material occupying center of lobules, the outer layers being more 
opaque (Pollock). 

split pea, and forms upon the outer surface of the lid 
a conspicuous little tumor, often oval in shape, with 
its long axis vertical (in correspondence with the direc- 
tion of the follicle) (see Plate I), not infrequently 
opens upon the conjunctival aspect of the lid — a rather 
lame effort of nature to bring the process to an end. 
Before this occurs the contents of the cyst, previously 
gelatinous, and consisting of the retained and altered 
secretions of the gland, usually become purulent (Fig. 



74 PREVALENT DISEASES OF THE EYE. 

1 6). After the perforation takes place a slight discharge 
from the cyst may continue for an indefinite period, and 
very often granulations sprout up from the edges of the 
fistula-like opening through which the discharge escapes. 
In rare instances the anterior wall of the cyst breaks 
down, and its contents are discharged through the 
dermal surface of the lid. 

Before the stage of perforation is reached, the chala- 
zion, unless it has become large enough to increase 
appreciably the weight of the lid or to interfere with 
its movements, gives rise to but little inconvenience, 
apart from its unsightliness; but, after the perforation 
occurs, and especially if granulations have formed, 
it causes more discomfort, partly from the discharge 
spreading over the cornea and partly from the mechan- 
ical irritation produced by the presence of the granula- 
tions. Chalazia form rather more frequently in the 
upper than in the lower lid, are prone to recurrence, 
though not in the same follicle, are often multiple, 
several occurring simultaneously in the lids of one 
or both eyes, and are most common in early adult life. 
The existence of chronic blepharitis marginalis is a 
distinctly predisposing cause, and so also, though less 
directly, is accommodative strain. As may be inferred 
from what has been said regarding their etiology, they 
are often encountered in persons who are subject to 
styes. 

Treatment. — It is sometimes possible to dissipate 
a chalazion, which is small and has only recently 
formed, by the application of the ointment of the 
yellow oxid of mercury or the ordinary mercurial 
ointment; but, as a rule, the only effectual method of 
treatment is operative The suggestion, often met with 
in text-books upon the eye, that chalazia should 



DISEASES OF THE EYELIDS AND ORBIT. 75 

be "dissected out" is ridiculous and should not be 
followed, because, in the first place, owing to the thin- 
ness of the cyst walls it is an almost impossible pro- 
cedure and, in the next place, it involves a very un- 
necessary traumatism of the eyelid. Except in rare 
instances, when the cyst is very superficial and shows 



Fig. 17. — Chalazion knife and sharp curet (about two-thirds actual size). 

a disposition to break through the skin, they should 
be attacked from the inner surface of the lid. When 
the lid is everted, a circumscribed purplish area is 
observed. This marks the location of the cyst, wmich 
will be found directly beneath it, and indicates the 
point at which the incision should be made. 




/ 

Fig. 18. — Operation for chalazion. Crucial incision into sac through con- 
junctival aspect of lid. 

The operation which I have found effectual, and 
which is very easy of performance, is as follows: The 
eye having been anesthetized by several applications of 
cocain and adrenalin solution (1 : 1000), the lid is everted 
and held securely in this position, either with or without 
the aid of a lid-clamp, as may be preferred. With a 



/6 PREVALENT DISEASES OF THE EYE. 

knife such as is shown in the illustration (Fig. 17) a 
crucial incision (the cuts being about 4 mm. in length) 
is made directly into the cyst (Fig. 18). The contents 
of the cyst are then removed with a sharp spoon (also 
shown in Fig. 17), and in doing this its walls are 
thoroughly scraped (Fig. 19). The small, bulbous tip 
of a silver probe, which has been previously coated 
with silver nitrate by being heated in a flame and 
brought in contact with a crystal or crayon of lunar 




Fig. 19. — Removing contents of sac and curetting its walls with sharp spoon. 

caustic, is now introduced into the cyst, and moved 
about so as to cauterize it thoroughly (Fig. 20). This 
completes the operation, and the lid, after having been 
washed clean with sterile water or a solution of boracic 
acid, is allowed to resume its normal position. No after- 
dressing is required, but it is a good plan to apply a 
poultice of flaxseed-meal to the lids the succeeding 
night. Considerable inflammatory reaction follows 
the operation; but this subsides quickly, leaving some 



DISEASES OF THE EYELIDS AND ORBIT. JJ 

induration which disappears in the course of a few 
weeks. The curetting and cauterization are necessary 
to prevent a re-formation of the cyst. The smaller 
the chalazion, the more difficult, as a rule, is the opera- 
tion. When the chalazion is in the low^er lid, the 
operation is also rather more difficult. In operating 
through the external surface of the lid the same pro- 
cedure is followed. 

Milium is the name given to a variety of sebaceous 




Fig. 20. — Cauterizing walls of sac with silver nitrate fused upon bulbous 
tip of silver probe. 

cyst, about the size of a millet-seed (hence the term), 
which occurs in the eyelid. It is white in color, round- 
ish, and slightly prominent. It causes no especial 
inconvenience, but is rather unsightly. 

Treatment. — It should be incised, the sebaceous 
contents removed with a small curet, and the cyst 
wall peeled out with slender, toothless forceps. It 
exhibits but little tendency to recur, when dealt with in 
this way. 



78 PREVALENT DISEASES OF THE EYE. 

Hydro cystoma. — Small, translucent cysts, contain- 
ing a clear, watery fluid, are occasionally observed in 
the lid. They result from occlusion of the duct of a 
sweat-gland, and may be gotten rid of by simple in- 
cision or, more surely, by excising, with slender curved 
scissors, the outer half of the cyst wall. 

Warts, usually of small size, are not uncommon 
upon the lids. They are found generally upon the 




Fig. 21. — Epithelioma of the eyelid (Ramsay). 

lid-margin, about the roots of the eyelashes. They 
are unsightly, but otherwise cause no inconvenience. 
They should be snipped off with curved scissors, and, 
to lessen the possibility of a recurrence, the base 
should be cauterized with a pointed crayon of silver 
nitrate. 

Malignant tumors of the eyelid are rare, if we ex- 
cept epithelioma, which is prone to occur here, as it 
does in other regions of the bodv where the skin and 
mucous membrane join (Fig. 21). They should be 



DISEASES OF THE EYELIDS AND ORBIT. 79 

dealt with promptly and radically, as they tend to 
invade the orbit (Figs. 23 and 24), causing not only loss 
of sight but loss of life from secondary involvement 
of the brain. They afford an especially favorable 




Fig. 22. — Syphilitic tarsitis (de Schweinitz). 

field for the Rontgen-ray treatment, provided this is 
employed before extension to the orbit has occurred. 
Tarsitis, or inflammation of the tarsal cartilage, 
characterized by hyperemia and nodular swelling of 
the lid, is commonly dependent upon acquired syphilis, 
occurring in the tertiary stage of the disease (Fig. 22). 



8o 



PREVALENT DISEASES OF THE EYE. 



It tends to run a chronic course, and is frequently 
accompanied by palpebral conjunctivitis. 

Constitutional as well as local treatment is called for. 
The biniodid of mercury, in doses of ^V to -^ of a 
grain, three times a day, and the yellow oxid ointment, 
applied to the lid morning and night, are the remedies 
indicated. 

Entropion, inversion of the eyelid, a very annoying 




Fig. 23. — Sarcoma of 
the lid and orbit (Frieden- 
wald). 




Fig. 24. — Dr. Friedenwald's case 
of sarcoma of the lid and orbit three 
months after operation.* 



condition because the eyelashes come into contact 
with the cornea, causing much irritation and not infre- 
quently superficial keratitis, occurs under two forms, 
one variety being known as spasmodic, the other as 
organic or cicatricial entropion. 

* The description of this case will be found in the " Trans. Am. 
Ophthalmological Soc." for 1900. There was no local recurrence 
of the disease ; but Dr. Friedenwald informs me the patient died 
fifteen months after the date of the operation, with symptoms indi- 
cative of metastatic involvement of the right lung. 



DISEASES OF THE EYELIDS AND ORBIT. 51 

Spasmodic entropion^ as its name implies, results 
usually from undue contraction of the orbicularis mus- 
cle, commonly dependent upon photophobia. It oc- 
curs also as a senile condition, arising from relaxation 
of the lid-structures, and occasionally develops as a 
result of bandaging the eyes after operations, such as 
cataract extraction. A predisposing cause — some fault, 
perhaps, in the form or firmness of the tarsal cartilage 
or in the arrangement of the orbicularis muscle — it 
would seem probable, is always present. 

Organic entropion is produced by the contraction 
of scar-tissue in or beneath the palpebral conjunctiva, 





Fig. 25. — Incomplete entropion of the upper lids with consequent tri- 
chiasis (de Schweinitz). 



and almost invariably is dependent upon chronic 

trachoma; exceptionally it is of traumatic origin. 

Both the upper and lower lids are liable to be involved. 

When, however, the fault is consequent upon trachoma, 

it is usually the upper lid that is most in-turned, and 

causes the greatest amount of trouble (Fig. 25). On 

the other hand, the lower lid is almost always affected 

in senile entropion, and, indeed, in the several varieties 

of spasmodic entropion it is commonly the lower lid 

that is misplaced. 

The treatment of entropion, which has for its object 

the replacement of the lid in its normal position, differs 
6 



82 PREVALENT DISEASES OF THE EYE. 

materially in the different types of the affection; the 
procedure to be adopted depends also upon whether 
the upper or the lower lid is involved. In spasmodic 
entropion, including the senile type, if the fault has 
existed only a short time, it is often possible to effect 
a cure by putting the lid in its normal position, and 
keeping it there for some days. When only the upper 
lid is involved, this may be accomplished by the careful 
application of a pressure bandage. A more effectual 
method of preventing the in-turning — applicable, espe- 
cially, to the lower lid — is the painting of several coats 
of contractile collodion upon the loose skin of the lid. 
The application must be repeated often enough to 
keep the lid constantly in proper position — usually once 
in two or three days. The collodion will "hold" very 
much better if, before applying it, the skin is sponged 
with alcohol or ether. 

When these expedients fail to remedy the defect, 
resort must be had to one of the many operations 
which have been devised for the cure of entropion. 

The procedure best adapted, in my judgment, to 
the correction of inversion of the lower lid — whether 
due to trachoma or of spasmodic origin — is one that, 
in recent years, at all events, has not received the con- 
sideration which, I think, it deserves. I refer to the 
production of a linear eschar near the margin of the 
lid by the application of caustic potash. My ex- 
perience with this operation — if it deserves to be called an 
operation — has been most satisfactory, and has induced 
me, heretofore, to point out its merits.* The aim is to 
produce an eschar, 4 or 5 mm. wide, parallel with the 

* In a paper published in the "Transactions of the American 
Ophthalmological Society" for the year 1898, and in the "American 
Journal of Ophthalmology," October, 1898. 



DISEASES OF THE EYELIDS AND ORBIT. 83 

lid-margin and extending nearly the whole length of 
the tarsus, the contraction resulting from which shall 
hold the lid in its normal position. 

In order that the caustic may be applied with the 
requisite degree of exactness, one end of the crayon 
employed must be carefully sharpened. This is easily 
accomplished by rubbing it upon wet blotting-paper. 
The very considerable pain caused by the action of 
the caustic may be materially lessened by soaking the 
lid for ten or fifteen minutes with a ten per cent, solu- 
tion of cocain, applied by means of a pledget of ab- 
sorbent cotton. As the destruction of tissue tends to 
spread considerably beyond the point where the caustic 
is applied, and as it is desirable that this should not 
approach nearer the lid-margin than \\ or 2 mm., 
the line of application of the crayon should be about 
4 or 5 mm. from the ciliary border. Along this line, 
the lid being held upon the stretch and pulled away 
from the eyeball, the point of the crayon should be 
drawn, back and forth, a number of times, until the 
epidermis is destroyed and the tissues beneath assume 
a brownish appearance (Fig. 26). The lid being still 
held so that it shall not become inverted, the action of 
the caustic is allowed to extend as far as may seem de- 
sirable. When this point is reached, its further action 
is arrested by the application of vinegar and water, equal 
parts, or acetic acid diluted with water to about an 
equivalent strength. Within a few minutes the eschar 
begins to contract, and the lid may then be released 
without fear of its turning in, as already, in most 
instances, the tendency to entropion has been overcome. 

It is seldom necessary to repeat the application of 
the caustic; but this can be readily done, if the effect 
of the first application has proved insufficient. Within 



8 4 



PREVALENT DISEASES OF THE EYE. 



a few weeks all traces of the eschar have disappeared, 
and usually it is not possible to detect that any opera- 
tion has been performed. 

In entropion of the upper lid the procedure just 
described is not effectual; for the cartilage of the upper 
lid, which is broader and thicker than that of the lower 
lid (Fig. 27), usually plays a more essential part in the 
production of the deformity, so that not much can 
be expected of any operation which accomplishes little 




Fig. 26. — The correction of entropion of the lower lid by the production 
of an eschar with caustic potash. 



else than the removal of a portion of the external in- 
tegument. However, in spasmodic entropion of the 
upper lid, which, as has been said, is a condition sel- 
dom encountered, if the skin of the lid is redundant, 
it is sometimes possible to correct the fault by the 
simple excision of a semilunar piece of the integu- 
ment, which is done in the following manner: A lid- 
spatula is placed beneath the lid, to support it, and 
two incisions are made through the skin, one parallel 



DISEASES OF THE EYELIDS AND ORBIT. 



85 



with and about 2 mm. from the line of the lashes, 
extending nearly the whole length of the tarsus; the 
other curvilinear, and reaching from one end to the 
other of the first incision. The degree of upward 
curve of the second incision will depend upon the 
amount of integument it is thought desirable to excise. 
The skin lying between the two incisions and a portion 




i_12 



Fig. 27. — Dissection of the tarsal plates and their ligaments (Testut): 
i, 2, Upper and lower tarsus; 3, 4, external and internal tarsal ligaments; 
5, expanded tendon of levator palpebras; 6, 6', septum orbitale; 7, lacrimal 
sac; 8, supraorbital vessels and nerve; 0, lacrimal artery and nerve; 10, 
11, openings for supratrochlear and infratrochlear nerves; 12, opening 
for the angular vein; 13, tendon of superior oblique muscle. 

of the orbicularis muscle beneath it are next removed, 
with the knife or scissors as may be preferred, and the 
operation is completed by bringing together the edges 
of the wound with three or four fine silk sutures. 
After three days union will have taken place, and the 
stitches may be removed. 

In the so-called organic entropion of the upper lid — 
that form which is commonly induced by trachoma — 



86 PREVALENT DISEASES OF THE EYE. 

a more radical procedure than the foregoing is de- 
manded. 

The operation which I have most frequently em- 
ployed in this condition, and usually with satisfactory 
results, is that which was suggested some years ago 
by Dr. John Green, of St. Louis. It is open to the 
objection, however, that it necessarily involves a very 
considerable traumatism of the tarsal cartilage and 
of the palpebral conjunctiva, and it has been largely 
supplanted by the procedure originally proposed by 
Anagnostakis, but which commonly goes by the name 
of Dr. Hotz, of Chicago, who, without knowledge of 
what had been done in this direction by Anagnostakis, 
re-contrived and perfected the operation, and brought 
its merits to the notice of the ophthalmic surgeons of 
the present day. 

Dr. Hotz's description of the operation, made very 
easy of comprehension by the accompanying excellent 
illustrations (Fig. 28), for which I am indebted to him, 
is as follows: 

"While an assistant fixes the skin at the supraorbital margin the 
operator, seizing the center of the lid-border with fingers or forceps, 
draws the lid downward to put its skin well on a stretch, and makes 
a transverse incision through the skin and orbicularis muscle from 
a point 2 or 3 mm. above the punctum lachrymale to a point 2 or 
3 mm. above the external canthus. This incision (Fig. 28, A) divides 
the lid-skin in a line parallel to and a little below the upper border 
of the tarsal cartilage, and is therefore from 4 to 8 mm. distant from 
the free border in the center of the lid. The skin and muscular layer 
are now dissected from the incision down to the roots of the eye- 
lashes, and, while an assistant is holding the edges of the wound 
well separated, the operator seizes with forceps and excises with 
curved scissors the muscular fibers running transverselv across the 
upper border of the tarsus. Next the sutures are inserted. Three 
sutures are usually sufficient — one in the center of the wound and 
one at each side of the central suture. The curved needle, armed 
with black silk No. 3, is first passed through the wound-border of 
the lid-skin (A, a); then it is thrust through the upper border of the 
tarsus and returned through the tarso-orbital fascia just above this 



DISEASES OF THE EYELIDS AND ORBIT. 



87 



border; and finally it is carried through the upper wound-border 
(b). When the sutures are tied the skin is drawn upward and fixed 
to the upper tarsal border (Fig. 28, B), and this slight traction is 
sufficient to turn the inverted lid-border and eyelashes to their 
normal position; and, as the skin becomes firmly united with the 
tarsal border, the tension thus produced upon the lid-border is per- 
manently secured." 

Under aseptic dressings the wound commonly heals 
without suppuration, and the stitches may be removed 
on the third or fourth day. 




Fig. 28. — A and B, Anagnostakis-Hotz operation for entropion. 



In the worst forms of entropion Dr. Hotz combines 
with the procedure just described a "reconstruction 
of the lid-margin." A deep incision is made in the 
free border of the lid, extending nearly its whole length 
and just behind the line of the lashes, great care being 
exercised that no lashes are left in the posterior lip of 
the divided lid-margin. The tension of the external 
integument of the lid produced by its attachment to 
the upper margin of the tarsal cartilage causes this 



88 PREVALENT DISEASES OF THE EYE. 

incision to gape considerably, and this gap is filled 
by a Thiersch graft — a narrow, wedge-shaped strip of 
skin, of suitable length, which may be obtained con- 
veniently from the posterior surface of the auricle or 
from the integument which covers the mastoid process. 
Sutures are not necessary to retain the graft in position; 
but it is desirable to bandage both eyes — for twenty- 
four or forty-eight hours — until it has become adherent. 

Ectropion. — Like entropion, eversion of the eyelid, 
or ectropion, may be produced by spasm of the orbicu- 
laris muscle, by contraction of scar tissue, or by senile 
relaxation and loss of tone of the lid-structures. It 
may occur also in consequence of paralysis of the 
orbicularis muscle. Both lids, the upper and the 
lower, are liable to be affected, the less pronounced 
forms being found, as a rule, when the displacement 
is in the lower lid; for the degree of eversion, it should 
be remarked, varies greatly — from a slight drooping 
of the lower lid, just sufficient to cause eversion of the 
punctum and consequent epiphora, to complete turning 
out of the conjunctival surface of the lid, giving rise 
to a revolting deformity. The slighter forms, affecting 
the lower lid, are those which result from senile changes, 
from paralysis of the orbicularis, and from eczema of 
the lid and cheek. The more pronounced types are 
due to spasm of the orbicularis or to cicatricial con- 
traction. 

Spasmodic ectropion develops usually during the 
course of an acute conjunctivitis or keratoconjunctivi- 
tis, attended by congestion and edema of the palpebral 
conjunctiva. As a rule, these conditions are accom- 
panied by photophobia and blepharospasm. When 
an attempt is made to examine such eyes, or to make 
applications to them, it is not uncommon for the lids, 



DISEASES OF THE EYELIDS AND ORBIT. 89 

the upper lid especially, to become everted. If this 
happens under the observation of the surgeon, the 
eversion, of course, is corrected at once and without 
difficulty. If, however, it occurs under other circum- 
stances, and if, so occurring, the displacement of the 
lid is allowed to remain for several days, the correction 
of the fault is no longer an easy matter. In fact, a 
condition comparable to paraphimosis has been brought 
about, and the' everted conjunctiva is now congested 
and greatly swollen, as a consequence of the strangula- 
tion produced by the action of the distorted orbicularis 
— a typical spasmodic ectropion has, indeed, already 
become established. Now, if the lid is returned to 
its normal position, it refuses to stay there. The 
faulty position has become, as it were, the " natural" 
position, and so it will ever remain, unless proper 
measures are taken to remedy the defect. Briefly told, 
this is the usual history of the development of spas- 
modic ectropion. 

Cicatricial or organic ectropion is commonly of trau- 
matic origin, though it may result from any lesion 
which leads to destruction of the external integument 
of the lid or of the neighboring parts. Burns, whether 
from hot substances or caustic agents, lacerated wounds, 
malignant growths, lupus, and caries of the bones 
forming the border of the orbit, are some of the con- 
ditions apt to produce it. The distortion and dis- 
placement of the lid occurring in this form of ectropion 
are often excessive (Fig. 29); nevertheless, the repulsive 
appearance characteristic of spasmodic ectropion is 
seldom present. 

The incomplete eversion of the lower lid caused by 
eczema of the lid and cheek is a not unusual complica- 
tion of disease of the lacrimal apparatus — of any con- 



9 o 



PREVALENT DISEASES OF THE EYE. 



dition, in fact, whether displacement or occlusion of 
the punctum, or stricture of the canaliculus or lacrimal 
duct, which may give rise to epiphora, the overflow 
of tears and mucus being the exciting and continuing 




Fig. 29. — Cicatricial ectropion following burn by molten lead (Haab). 




Fig. 30. — Ectropion of the lower lid due to facial paralysis (Haab). 



cause of the eczema, which, through the resulting skin 
contraction, drags the lid from its normal position. 
In this way, too, senile ectropion and the ectropion 
of facial paralysis (Fig. 30) are often greatly aggravated; 
for the malposition of the lower punctum present in 



DISEASES OF THE EYELIDS AND ORBIT. 91 

both of these conditions usually gives rise to epiphora, 
and, sooner or later, a dermatitis of the lid and cheek 
develops. 

A more marked type of ectropion of the lower lid, 
attended by considerable elongation of the lid-margin, 
is met with in certain cases of chronic inflammation 
of the lids and conjunctiva (Fig. 31). Its occurrence is 




Fig. 31. — Ectropion of the lower lids (de Schweinitz and Randall). 



due measurably to the hypertrophied condition of the 
palpebral conjunctiva; but it seems probable that other 
factors, such as an ill-shaped tarsus or a badly disposed 
orbicularis muscle, have to do with its development 

( Fi g- 32). 

Treatment. — The slighter degrees of ectropion of 
the lower lid, such as occur in facial paralysis or from 
senile atrophy or eczema of the cheek, are chiefly 



92 PREVALENT DISEASES OF THE EYE. 

annoying because of the epiphora to which they give 
rise. They require, therefore, no treatment beyond 
the slitting . of the lower canaliculus. This simple 
procedure not only does away with the epiphora, but, 
by preventing the excoriation of the skin by the over- 
flowing tears, not infrequently materially lessens the 
malposition of the lid. 

In spasmodic ectropion, of not too long duration, it 
is often possible to effect a cure by replacing the everted 




Fig. 32. — The orbicularis muscle and the internal palpebral ligament 
(Nunneley). The palpebral ligament is seen at a; b and d indicate the 
palpebral and orbital portions of the orbicularis muscle. 

lid and applying a compress bandage. After this has 
been worn for two or three days the tendency of the 
lid to become everted will have been overcome. When 
this plan fails, the procedure suggested by Snellen 
should be resorted to, and will usually be found effica- 
cious, unless the condition has lasted so long that the 
lid-margin has become considerably elongated. The 
steps of Snellen's operation, which is applicable to 
either lid, are as follows: A curved needle is attached 
to each end of a silk thread, and both needles are 



DISEASES OF THE EYELIDS AND ORBIT. 93 

passed, from within outward, through the whole thick- 
ness of the lid. The points of entrance should be 5 
or 6 mm. apart, and at such a distance from the border 
of the lid that the needles shall pass through the convex 
margin of the tarsus. The points of exit should be 
about a centimeter apart and two centimeters from 
the lid-margin. Sufficient traction is now made upon 
the thread to cause the lid to assume its proper position, 
and the two ends are then tied rather tightly over a piece 
of small rubber tubing or a roll of adhesive plaster, 
which prevents the thread cutting into the skin. To 
effect the desired result two, or possibly three, threads 
may sometimes be required. A light bandage should 
be worn for several days, and on the fourth day the 
stitches should be removed. 

To facilitate the replacement of the lid, excision of a 
portion of the congested and swollen palpebral con- 
junctiva is recommended; but the end in view, it 
would seem, might be attained as well through the 
markedly astringent action of adrenalin. 

When ectropion is attended by considerable elon- 
gation of the lid-border, a shortening of the lid be- 
comes an essential part of any operation undertaken 
for the correction of the deformity. This was accom- 
plished at one time by excising a wedge-shaped piece 
from the center of the lid, but a better procedure, 
and the one now usually employed, is to remove the 
piece at the outer canthus, as suggested by von Ammon. 
The amount of shortening required will, of course, 
determine the size of the wedge to be removed. The 
edges of the incision (Fig. 33, A) should be brought 
together accurately by three or four silk sutures, or 
by a harelip pin, as shown in Fig. 33, B. 

The form of ectropion most difficult to correct is 



94 PREVALENT DISEASES OF THE EYE. 

that which is produced by the contraction of scar- 
tissue, and innumerable ingenious operations have 
been contrived for this purpose. In cicatricial ectro- 
pion the lid, besides being everted, usually is elongated 
and dragged away from its proper position. It may 
be also so immovably fixed in this new position that 
closure of the eye is quite impossible. 

The first step in every operation for the correction 
of this variety of ectropion is the freeing of the lid 
from its attachments, so that it may be brought into 
normal relation with the eye and with the fellow-lid. 
The completion of this step usually leaves, in the 





A B 

Fig. 33. — Von Amnion's operation for shortening the lid. 

neighborhood of the orbital margin, a more or less 
extensive area denuded of integument, and the filling 
of this gap with skin, which is necessary to prevent 
a re-displacement of the lid, constitutes the second 
and final step of the operation. Formerly this was 
accomplished by some form of plastic operation, usu- 
ally by the transplantation of flaps of skin from the 
neighboring parts — the forehead, the temple, or the 
cheek. There were, however, many difficulties and 
disadvantages connected with such operative proced- 
ures, and of late they have been in large measure aban- 
doned, and have been supplanted by the modern meth- 
ods of skin-grafting devised by Wolfe and Thiersch. 



DISEASES OF THE EYELIDS AND ORBIT. 



95 



When the ectropion involves the lower lid its re- 
placement, which usually includes a shortening of 
the lid-border, is commonly effected by the operation 
proposed by Arlt. As represented in Fig. 34, A, two 
converging incisions, a b, b d, are made through the 
whole thickness of the skin, or through the scar-tissue 
which has taken its place. The included integument 
is then dissected up until the lid is free, and can be 
restored to its normal position. Next, the lid-border 
is shortened at the outer canthus, in the manner already 





Fig. 34. — A, Arlt's operation for cicatricial ectropion of lower lid; B, 

final stage. 



described. An effort is then made, by undermining 
the margins of the incision, a g d (Fig. 34, B), to 
close the V-shaped gap, the edges being brought to- 
gether by harelip pins. If this cannot be done without 
undue traction, or if after it is accomplished a gap is 
left above which cannot be closed except by such 
tension upon the flap, a b d, as might result ultimately 
in a recurrence of the ectropion, resort should be had 
to skin-grafts with which to fill in any existing gaps. 
Hotz, who has given special attention to operations 
upon the lids, recommends that for this purpose grafts 



96 PREVALENT DISEASES OF THE EYE. 

obtained by the Wolfe method should be employed. 
The grafts, which include the whole thickness of the 
skin, but which should be freed carefully from any 
underlying fat, may be obtained most advantageously 
from the inside of the arm or forearm. They should 
be shaped to fit accurately the space into which they 
are to be inserted, and as outlined upon the skin of 
the arm should be about one-third larger than this 
space, to allow for the usual shrinkage. No sutures 
are required to maintain them in position; but, after 
they have been adjusted carefully, they should be 
covered with several layers of silver-foil. Over this 
a pad of sterile gauze and absorbent cotton, of suffi- 
cient thickness to afford equable support, is placed, 
and is kept in position by a light bandage or by sev- 
eral strips of rubber adhesive plaster. Owing to the 
overflow of the secretions from the eye, it is usually 
necessary to change the dressings on the third or 
fourth day; otherwise, it would be advantageous 
to allow them to remain for ten or twelve days. 

The use of silver-foil as a surgical dressing, first sug- 
gested by Dr. Wm. S. Halsted, has been employed exten- 
sively for some years in the Johns Hopkins Hospital. 
All fresh wounds, both closed and open, are invariably 
dressed with it, and as a covering for the moist blood- 
clot and for skin grafts it has been found especially 
valuable. Dr. Halsted advises that it should be 
"laid on without stint, at least three or four layers 
thick, and should be protected from the outer (gauze) 
dressing by two or three layers of the foil-paper. " 

To maintain the replaced lid in its proper position 
and to guard against a recurrence of the ectropion, 
it is usual, before inserting the grafts, to unite the 
margins of the upper and lower lids by three sutures, 



DISEASES OF THE EYELIDS AND ORBTT. ()J 

which, if deemed necessary, may be left in position 
for several weeks. 

In dealing with ectropion of the upper lid, owing 
measurably to the presence of the eyebrow, the 
V-shaped incision of Arlt does not yield satisfactory 
results. The method of procedure to be adopted for 
the correction of this defect will vary necessarily with 
the conditions to be met; but, in general, it will consist 
of a freeing of the retracted and everted upper lid, so 
that it can be brought into proper relation with the 
eye and with the fellow-lid (to which it should be 
attached by sutures, as in the previously described 
operation), and the filling of the resulting gap by 
Wolfe or Thiersch grafts. The Thiersch grafts afford 
a thinner and more flexible tissue, and for this reason 
are preferable if they are to form a part of the lid 
proper (Hotz); but, owing to the marked shrinkage 
which they undergo, a recurrence of the ectropion is 
liable to occur if they are depended upon to fill in 
gaps of considerable size. A combination of the two 
methods, therefore, may be employed advantageously 
when this condition has to be met — Wolfe grafts being 
used to fill large gaps upon the temple or above the 
brow; Thiersch grafts, to build up the lid itself. 

The Thiersch grafts, which consist only of the 
epidermis and the very superficial layers of the dermis, 
carefully shaved off with a razor or other keen-edged 
blade, may be employed to excellent purpose to pre- 
vent the development of ectropion, since they can be 
"planted" upon granulating surfaces as well as upon 
fresh wounds. For this reason, too, it is possible to 
apply supplementary grafts, should any of those ap- 
plied at a previous operation fail to "take." 

Sepsis should be carefully guarded against in skin- 
7 



98 PREVALENT DISEASES OF THE EYE. 

grafting. The surface from which the graft is to be 
taken, as well as that to which it is to be transferred, 
should be rendered as nearly as possible aseptic, and 
all dressings employed, including, of course, the silver- 
leaf, should be sterile. For this purpose sublimate 
solutions are used more freely in the surgical service 
of the Johns Hopkins Hospital than was at one time 
thought advisable. 

Ptosis, a drooping of the upper lid with inability to 
elevate it, occurs as a congenital and as an acquired 
condition. The fault is usually in the levator muscle, 
though exceptionally the defect may be due to increased 
weight of the lid from inflammatory hypertrophy or 
other cause. Acquired ptosis is commonly a result of 
paralysis of the third nerve, a twig from which supplies 
the levator muscle, and is very often dependent upon 
syphilis. When this is the case, the other ocular 
muscles supplied by the third nerve are usually in- 
volved, and, besides drooping of the lid, we have 
divergent squint, inability to turn the eye inward, up- 
ward, or downward, mydriasis, and loss of accommoda- 
tive power. Exceptionally only that branch of the 
third nerve which supplies the levator muscle is af- 
fected. Such a condition may be caused by central 
disease, or it may occur as a result of traumatism or 
from pathological processes in the orbit. 

Congenital ptosis, which is commonly bilateral — 
acquired ptosis being more often monolateral — is not 
infrequently an inherited condition. It is caused by 
faulty innervation, or by imperfect development or 
actual absence, of the elevator muscle of the lid. The 
subjects of this defect acquire the habit of employing 
the occipitofrontalis muscle to lift the lids, so that 
the eyebrows are unduly elevated. They are inclined 



DISEASES OF THE EYELIDS AND ORBIT. 99 

also to throw the head backward, since this makes it 
easier for them to see straight forward, as the upper 
lid,* under such circumstances, need not be elevated 
as much as would otherwise be necessary. They 
present, therefore, an odd and characteristic appear- 
ance, which is well shown in the accompanying illustra- 
tion (Fig. 35). The appearance exhibited in acquired 
monolateral ptosis, if it is complete — for varying de- 
grees of both congenital and acquired ptosis are met 




Fig. 35. — Congenital ptosis (T. C. Evans). 



with — is exactly that of a person who, keeping one 
eye open, succeeds in closing the other without ap- 
parent muscular effort (Fig. 36). 

Treatment. — In congenital ptosis only operative 
treatment is of avail; on the other hand, in acquired 
ptosis operative measures should be resorted to only 
when all other means have been tried, and have proved 
ineffectual. As a rule, if the condition is not of long 
standing, the prognosis in acquired ptosis is favorable. 



<-. ut -.-. 



100 PREVALENT DISEASES OF THE EYE. 

This is true, especially, of the many cases which are 
of luetic origin. In these cases, as well as in those 
dependent upon rheumatism, potassium iodid, in 
liberal doses, is perhaps the most valuable remedy 
we possess. The biniodid of mercury is another valu- 
able remedy, and with either of these strychnin may 
be advantageously combined. Counter-irritation, by 




Fig. 36. — Acquired ptosis with cystic tumor of orbit (de Schweinitz and 

Randall). 



means of blisters applied to the forehead or temples, 
at times seems to exert a good effect. I have not much 
confidence in the efficacy of galvanism in these cases; 
but some authorities, probably with larger experience 
in its use, hold it in higher esteem. When constitu- 
tional treatment has been given a thorough trial without 
effect, and only then, resort should be had to one of 
the operative measures presently to be described. 



DISEASES OF THE EYELIDS AND ORBIT. IOI 

For the correction, more especially, of congenital 
ptosis, innumerable operative procedures, and num- 
berless modifications of previously suggested operations, 
have been proposed. When so many plans are sug- 
gested to meet a given condition the inference is war- 
ranted that no one of them is entirely satisfactory, 
and this is certainly true of the many operations de- 
vised for the correction of ptosis. 

All of these procedures, with one or two unimportant 
exceptions, aim either to shorten the eyelid, so that 
it shall not interfere so greatly with vision, or to render 
more effective the vicarious action of the occipito- 
frontalis muscle in its endeavor to take the place of 
the incapacitated levator palpebral. 

The objection to those operations which aim at 
shortening the lid is that in ptosis, as a rule, the lid 
is not elongated. Indeed, in congenital ptosis, perhaps 
in consequence of the long-continued action of the 
occipitofrontalis, it not infrequently appears to be 
preternaturally short. If under such circumstances it 
is shortened still more, sufficiently to raise it above the 
level of the pupil, there is great danger of producing 
the condition known as lagophthalmos — inability to 
close the eye or, at all events, to keep it closed without 
actual effort — a condition which, especially through 
lack of protection of the cornea during sleep, may lead 
to serious consequences. If, however, there is actual 
elongation of the lid, and sometimes when it is only 
of the usual length, as is more apt to be the case in 
acquired ptosis, much relief may be afforded by an 
operation which will shorten it to the degree required. 

The shortcoming in those procedures which undertake 
to render the action of the occipitofrontalis more effec- 
tive is that, notwithstanding our best efforts in this 



102 PREVALENT DISEASES OF THE EYE. 

direction, the part of levator of the lid is played by 
this muscle in rather lame fashion. 

Of the various operations proposed for shortening 
the lid, the most rational is the procedure first sug- 
gested by Bowman, in 1859 — the removal of a portion 
of the tarsal cartilage.* The credit of originating this 
operation is commonly given to Gillet de Grandmont; 
but the procedure which he described in 1891,"}" though 
differing in minor details, is essentially that which 
Bowman employed thirty-two years before. Quite re- 
cently this operation has been somewhat modified and 
improved upon by Gruening, who speaks enthusias- 
tically of the excellent results which it has afforded 
him. His modification consists chiefly in the method 
of introducing the sutures which are employed to bring 
together the edges of the divided cartilage. 

Like de Grandmont, Gruening makes an incision, 
corresponding in length with the tarsus, through the 
external integument of the lid, parallel with and about 
3 mm. from its free border, and, after dissecting back 
the skin and orbicularis muscle until the whole tarsal 
cartilage is exposed, removes a semilunar piece of the 
cartilage and the subjacent conjunctiva by two incisions, 
one straight and parallel with the lid-margin, the other 
curvilinear, with its convexity upward, and joining the 
extremities of the first incision. The breadth of the 
piece of cartilage to be removed is determined by the 
effect desired. If a shortening of the lid amounting to 6 
mm. is desired, the excised piece should have a breadth 
in the center of 6 mm. and at each extremity of 2 mm. 
The upper border of the cartilage Gruening, following 

* "Royal London Ophthalmic Hospital Reports," Vol. I, p. 34. 
f " Journ. de Med. de Paris," 1891^.296. 



DISEASES OF THE EYELIDS AND ORBIT. 



IO3 



the example of Heisrath,* leaves intact, so that the 
cartilage is actually cut in two, a crescentic piece being 
left above, a long strip, with nearly parallel sides, below 

(Fig- 37)- 

In de Grandmont's operation the deep parts of the 

wound are united by three catgut sutures, which are 

left to undergo absorption, the skin being closed over 

them. Gruening, on the other hand, brings the lips 

of the cartilage wound into apposition by means of 

three double-armed silk threads. The needles at- 




k„h*l i 



Fig. 37. — Gruening's modification of the Bowman -de Grandmont opera- 
tion for ptosis. 



tached to each of these are passed first through the 
lower edge of the upper, crescentic portion of the 
divided cartilage, then downward through the lid 
structures, as shown in the illustration, and, finally, 
are brought out upon the free border of the lid, behind 
the lashes, where each pair of threads is tied, after 
having been drawn tightly enough to close the cartilage 
wound. The skin wound may be closed by several 
superficial sutures, though this is hardly necessary. 

* "Berliner klin. Wochenschrift," 1891, p. 58. 



104 



PREVALENT DISEASES OF THE EYE. 



The deep sutures are removed on the fifth day. With 
proper antiseptic precaution these sutures are not 
likely to excite undue inflammatory reaction, and, on 
the whole, are to be preferred to the buried stitches 
of de Grandmont. 

Of the operations designed to render more effective 
the action of the occipitofrontalis in lifting the lid, that 
contrived by Panas affords the best results. By refer- 
ence to the illustrations (Figs. 38 and 39) the steps of 
this operation are made easily comprehensible. A 
horizontal incision, 2 cm. long, is made through the 




Fig. 38. — Panas's operation for ptosis. Fig. 39. — Panas's operation concluded. 



skin and orbicularis muscle a short distance below the 
upper margin of the orbit. From near each extremity 
of this incision two vertical incisions are carried down- 
ward to a point 2 or 3 mm. below the upper margin 
of the tarsal cartilage, where each incision is continued 
horizontally, as shown in the illustration. The flap 
of skin and muscle thus formed is then dissected up 
from the underlying fascia and cartilage. Another 
incision, 3 cm. long, is next made through the skin and 
muscle just above, and following the curve of, the eye- 
brow, and the bridge of skin between this incision and 



DISEASES OF THE EYELIDS AND ORBIT. IO5 

the lower incision is undermined. By means of three 
sutures introduced near its upper margin, and passed 
beneath this bridge of skin, the flap is now drawn up 
under the bridge, and attached to the upper edge of 
the incision above the brow. To prevent the traction 
which results from causing eversion of the lid-margin, 
two lateral sutures, as shown in the illustration, are 
passed through the tarso-orbital fascia and conjunctiva, 
without including the skin, and are carried up subcu- 
taneously and attached, like the previously mentioned 
sutures, to the lip of the upper incision. 

The effect of the operation, in lifting the lid, will 
depend largely upon the width of the undermined 
bridge of skin, or, in other words, upon the distance 
between the two horizontal incisions If this is too 
great, the effect will be excessive; if not great enough, 
it will be insufficient. It is a matter of importance, 
therefore, taking into account the degree of ptosis and 
the redundancy or scantiness of the integument of the 
lid, to determine how considerable this distance shall be. 
The operation being completed, the wounds should be 
covered with silver-foil, and over this a pad of sterilized 
gauze should be applied; and on the fourth or fifth 
day the stitches should be removed. 

Paralysis of the facial nerve, a condition nearly 
always unilateral, affects the eye through loss of power 
of the orbicularis muscle (Fig. 40) The lids do not 
close properly, and the lower lid tends to sag, so that the 
lacrimal punctum fails to maintain its normal position 
with reference to the eyeball. In consequence of this, 
epiphora is commonly present. Partly owing to the 
epiphora, and still more because the lids do not afford 
the usual protection to the eye, conjunctivitis, and less 
frequently keratitis, may develop. When the paralysis 



106 PREVALENT DISEASES OF THE EYE. 

is complete, the eye cannot be closed, and when an 
effort is made to close it, the eyeball is turned strongly 
upward in a manner which is quite characteristic. 

The lesion causing the palsy is usually peripheral, 
and may involve the nerve during its course through 
the temporal bone or after its emergence from the 
stylomastoid foramen. Disease of the middle ear is 
probably the commonest cause of facial paralysis. It 




Fig. 40. — Right -sided facial paralysis, showing inability to close the lids 
from involvement of the orbicularis palpebrarum (Ramsay). 



may also follow surgical operations or other trau- 
matisms involving the tympanum. It is sometimes 
dependent upon syphilis, and it may be brought on 
by exposure to draughts or to cold. It is also met 
with in connection with hemiplegia, and, according to 
the location of the intracranial lesion, may be on the 
same side as the hemiplegia or on the opposite side. 
Treatment. — This will depend, of course, upon the 



DISEASES OE THE EYELIDS AND ORBIT. IO7 

cause of the attack. In recent cases the prognosis usu- 
ally is favorable. As a matter of routine, it is well al- 
ways to examine the ear, unless it is manifest that 
the lesion is located elsewhere. Potassium iodid in 
liberal doses is indicated, and its usefulness is by no 
means limited to the cases of syphilitic origin. Strychnin 
also is useful, and some authorities place reliance in 
electricity. Small blisters, applied in front of the 
auricle, seem at times to be of benefit. When disease 
of the middle ear is present, its treatment is of the first 
importance. 

If keratitis develops, measures should be taken to 
insure proper protection of the cornea by the lids. 
This is especially important during sleep, as more pro- 
longed exposure of the eye is then apt to occur. This 
may be accomplished by the application over the lids of 
a light bandage, or a gauze compress, held in place by 
two or three strips of rubber adhesive plaster. 

The most useful application for the keratitis is a 
collyrium of holocain and boracic acid (holocain hydro- 
chlorate, gr. j; acid, boracic, gr. x; aquae, destil., oj), 
which may be dropped into the eye three to five times 
a day. When only conjunctivitis is present, a ten- to 
fifteen-grain solution of boracic acid, or a sublimate 
solution (1 : 8000 to 1 : 12,000), should be prescribed. 



DISEASES OF THE ORBIT. 
Diseases of the orbit hardly deserve to be regarded 
as among the more prevalent affections of the eye. 
However, it will not be out of place to treat briefly of cel- 
lulitis of the orbit, of periostitis and caries of the or- 
bital walls, and of the orbital tumors which are most 
frequently encountered. 



108 PREVALENT DISEASES OF THE EYE. 

Cellulitis of the orbit, leading usually to abscess, 
or phlegmon (Fig. 41), occurs as an acute affection and, 
less frequently, as a subacute or chronic process. It 
may arise from a variety of causes, such as local injuries 
of various sorts, "cold," the extension of inflammation 
from the integument of the face, as in facial erysipelas, 
or from the sinuses accessory to the orbit, periostitis 
of the orbital walls, panophthalmitis, and meningitis. 
It occurs also as a post-typhoidal and a post-scarlatinal 
affection, and as a manifestation of a general pyemia. 

The acute form of the disease is characterized by 




Fig. 41. — Orbital abscess (Ramsay). 

headache, severe pain in the orbit, increased by pressure 
upon the eye or by an attempt to rotate it, protrusion 
of the eyeball, with limitation of its movements, marked 
injection and chemosis of the conjunctiva, and redness 
and brawny swelling of the lids. It is commonly at- 
tended also by evidences of constitutional disturbance, 
such as elevation of temperature, loss of appetite, 
sleeplessness, etc. In the chronic type of the affection 
all the symptoms are less pronounced; they are also 
less typical, and in consequence a correct diagnosis 
is not so easily made. 

The prognosis in the milder cases, which may ter- 



DISEASES OF THE EYELIDS AND ORBIT. IOO, 

minate without suppuration, is favorable. But in the 
more severe cases, especially in those which are conse- 
quent upon facial erysipelas, the prognosis is grave; 
for not only is there danger of loss of sight from involve- 
ment of the optic nerve, or from necrosis of the cornea 
or the supervention of panophthalmitis, but a fatal 
result may ensue, through extension of the suppurative 
process to the brain or through the occurrence of a 
general pyemia. 

Because of the great swelling of the lids and the 
conjunctival chemosis, acute cellulitis of the orbit may 
be mistaken for gonorrheal conjunctivitis or for pan- 
ophthalmitis. However, it may be distinguished from 
the former affection by the existence of exophthalmos, 
by limitation of the movements of the eye, and by 
the absence of copious purulent discharge, and from 
the latter, by the fact that the cornea is clear — not 
opaque and necrotic, as it usually is in panophthalmitis. 

Treatment. — This should be both local and constitu- 
tional. In the acute form of the disease the local treat- 
ment should consist in the constant application of a 
warm anodyne fomentation — the lotion of opium and 
boracic acid, applied by means of a gauze pad covered 
with rubber protective, as previously described (ext. 
opii., gr. x-xv; acid, boracic, gr. xl; aq. destil., 3jv) 
— and an early incision, to afford efficient drainage. 

The incision, which it may be necessary to extend 
deeply into the orbit, should be made from the con- 
junctival cul-de-sac or through the lid, as may seem 
to be indicated. A straight, narrow bistourv should 
be used, and the blade should be entered flatwise with 
reference to the eyeball, to avoid the risk of wounding 
it. It is well, too, to bear in mind that if the incision 
is made in the upper nasal, or in the lower nasal, angle 



110 PREVALENT DISEASES OF THE EYE. 

of the orbit, there is danger that one or the other of 
the oblique muscles may be divided. In severe cases, 
especially those of erysipelatous origin, it may be neces- 
sary to make several incisions. The introduction of 
an iodoform-gauze drain is indicated when the sup- 
puration is deeply seated or when the external wound 
shows a disposition to close. Systematic syringing of 
the pus cavity with a warm antiseptic solution (a satu- 
rated solution of boracic acid, a one per cent, solution 
of carbolic acid, or a i : 8000 to 1 : 4000 sublimate 
solution) should be practised, and, if the discharge is 
considerable, should be repeated two or three times 
a day. 

Should panophthalmitis develop during an attack of 
orbital cellulitis, enucleation of the eye, in my opinion, 
should be performed without unnecessary delay. 
Resort to this measure, under such circumstances, is 
commonly condemned, upon the ground that the 
danger of cerebral infection is increased through the 
consequent opening of the lymph-channels of the optic 
nerve; but, it seems to me, any added risk from this 
source is more than offset by the greatly improved 
drainage of the orbit afforded by the removal of the 
eye, besides which the operation may be counted upon 
to relieve the patient of much suffering and, in all 
probability, to considerably curtail the duration of the 
orbital inflammation. The possible dependence of the 
cellulitis upon periostitis or caries of the orbital walls 
should not be lost sight of. 

The constitutional treatment of the acute form of 
the disease should consist in the administration of an 
energetic mercurial purgative, to be followed by liberal 
doses (gr. xx every two hours) of sodium pyrophosphate. 
Iron and quinin may also be called for. In the chronic 
form, tonics and alteratives are indicated. 



DISEASES OF THE EYELIDS AND ORBIT. Ill 

Periostitis, Caries, and Necrosis of the Orbital 
Walls. — Periostitis of the walls of the orbit, leading 
frequently to caries and not rarely to necrosis, is met 
with as a chronic and as an acute affection. Its most 
common causes are syphilis, inherited and acquired, 
rheumatism, scrofula, local injuries, and disease of 
the accessory cavities. 

The symptoms of acute periostitis resemble those 
of orbital cellulitis, to which, indeed, it not infrequently 
gives rise. Deep-seated pain, increased by pressure 
upon the eyeball, edema of the lids, conjunctival 
hyperemia, limitation of the movements of the eye, 
attended, perhaps, by diplopia, and more or less 
evident exophthalmos, are the usual symptoms when 
the disease occurs in the deeper parts of the orbit. 
When it is situated nearer the orbital margin, localized 
tenderness, manifested upon pressure on or beneath 
the border of the orbit, is a characteristic symptom, 
and, under such circumstances, it is often possible to 
detect the thickening of the periosteum. 

Suppuration is more apt to occur when the periostitis 
is of tuberculous or of traumatic origin, or when it is 
secondary to disease of the neighboring cavities. It is 
least apt to happen, and the affection is more prone 
to be chronic, when it is dependent upon rheumatism 
or syphilis. 

When the inflammation is pronounced, and involves 
the apex of the orbit, loss of sight may occur through 
compression of the optic nerve. Again, if caries and 
necrosis supervene, especially when the roof of the orbit 
is involved, intracranial complications may result. If 
suppuration takes place in the cellular tissue of the 
orbit, any of the untoward consequences w T hich have 
just been described in treating of this condition may 



112 PREVALENT DISEASES OF THE EYE. 

ensue. Furthermore, when exit has been given to the 
pus the discharge is apt to persist, and a fistula to 
become established, which will not close until the 
disease of the bone has been overcome. One of the 
unpleasant consequences to which this is apt to give 
rise is a permanent distortion of the lid, usually a more 
or less pronounced ectropion (Fig. 42). 

Treatment. — This will depend, of course, upon the 
character of the attack, its cause, and upon the extent 




Fig. 42. — Ectropion of upper lid from caries of orbital roof (author's 

case). 



to which the bone has become involved. The salicy- 
lates and potassium iodid' are indicated when the 
affection is of rheumatic origin, and the latter, in com- 
bination, perhaps, with mercury, when it is dependent 
upon constitutional syphilis; iodid of iron, cod-liver 
oil, and the hypophosphites when it is tuberculous. 

An early incision is called for when suppuration 
supervenes, to be followed by systematic syringing with 
an antiseptic solution; and, as caries is usually present 
under such circumstances, treatment directed to this 



DISEASES OF THE EYELIDS AND ORBIT. II3 

condition should be instituted when the acute symp- 
toms have subsided. Careful curetting may become 
necessary; but before this is resorted to, or as sup- 
plementary to it, an effort should be made to remove 
any dead bone which may be present, and to bring 
about a healthier action in the periosteum and in the 
bone itself, by the use of hydrochloric acid. 

If the carious bone is so situated as to be readily 
reached, the application of the acid may be made most 
effectually by means of a probe armed with a bit of 
absorbent cotton. The acid (c. p.) should be diluted 
at first with three or four parts of water; but, if well 
received, the strength of the solution may be gradually 
increased to equal parts of each. I have had but little 
experience in treating caries of the orbit in this way; 
but I have obtained very satisfactory results in caries 
of the walls of the auditory canal from the employment 
of hydrochloric acid in this manner. If it is imprac- 
ticable to make the application in this direct way, the 
sinus leading to the carious bone may be syringed 
with a much weaker solution of the acid — a two to four 
per cent, solution to begin with, which may be gradu- 
ally increased to twenty or twenty-five per cent, if 
well borne. 

Tumors of the Orbit. — Tumors of many kinds, 
malignant as well as benign, are met with in the orbit. 
They may have their starting-point in the orbital cel- 
lular tissue, in the lacrimal gland, in the optic nerve 
(Fig. 43), in the bony walls which surround the orbit; 
they may invade the orbit from one of the neighboring 
cavities, or they may begin as intraocular growths. 

Benign tumors developing in the orbit may cause 
serious consequences through interference with vision. 
In the case of malignant tumors the prognosis is most 

8 



ii 4 



PREVALENT DISEASES OF THE EYE. 



unfavorable, not only as to sight, but as to life, since 
they are prone to recur even after most thorough re- 
moval, and, sooner or later, are apt to involve the 
brain by extension along the optic nerve or through 
the roof of the orbit. 

Among the benign tumors occurring in the orbit 




Fig. 43. — Exophthalmos from fibroma of the optic nerve. The 
morbid growth in this case extended into the optic foramen, at which point 
chlorid-of-zinc paste was applied after removal of the eyeball and growth, 
without exenteration. Ten years later there had been no recurrence 
(Buller). 

may be mentioned lipoma, fibroma, dermoid, sebaceous 
and hydatid cysts, angioma, osteoma, and gumma. 
The malignant growths include the several varieties 
of sarcoma (Fig. 44), epithelioma, usually through ex- 
tension from the lids or eyeball, and carcinoma, com- 
monly having its starting-point in the lacrimal gland. 
Exophthalmos, lateral displacement and limitation of 



DISEASES OF THE EYELIDS AND ORBIT. 



"5 



the movements of the eyeball, diplopia, impairment of 
vision through involvement or compression of the optic 
nerve, and in the end desiccation and necrosis of the 
cornea from lack of protection, are commonly observed 
when the growth has attained a considerable size. 

In endeavoring to determine the character of the 
growth, palpation is at times of much assistance. One 




Fig. 44. — Sarcoma of the orbit originating in the tissues of the apex (Buller). 



should also take into account the history of the case, 
the rapidity with which the tumor has developed, the 
presence or absence of pain, the age and general con- 
dition of the patient, and the state of the nose and of 
the other cavities accessory to the orbit. The possi- 
bility that the growth may be of syphilitic origin should 
not be lost sight of; for when this is the case not 



Il6 PREVALENT DISEASES OF THE EYE. 

only is the treatment different, but the prognosis is 
decidedly more favorable. 

Treatment. — The presence of an orbital tumor having 
been definitely determined, its removal is commonly 
indicated. There are exceptions, however, to this 
rule. For example, if the tumor is benign, is causing 
no inconvenience, is not increasing in size, and is not 
readily accessible, it is permissible to postpone opera- 
tive interference as long as these conditions maintain. 
Again, when it is evident that a malignant growth 
starting in the orbit has already invaded the neighboring 
cavities, or it is clear that such a growth has involved 
the orbit only secondarily, having had its starting-point 
in one of these cavities, since no operative procedure, 
however radical, is likely to be of avail, either in re- 
lieving suffering or in prolonging the life of the patient, 
there is little justification for undertaking it. 

In dealing with benign tumors it is usually practica- 
ble, and one should always endeavor, to accomplish their 
removal without sacrificing the eyeball or in any way 
impairing the sight. In the case of malignant growths, 
however, the preservation of sight becomes a matter of 
secondary importance, and not only the eyeball but all the 
contents of the orbit (exenteration of the orbit), and in 
some instances the lids and portions of the orbital walls, 
must be removed (Fig. 45). Cosmetically, the effect 
of such an operation is, at first, rather shocking; but 
it is surprising how well nature copes with a condition 
so unpromising. In time the orbit becomes greatly 
lessened in depth, and its walls become lined with skin 
and scar-tissue, so that the unsightliness in large measure 
disappears. (In illustration of this, compare Figs. 45 
and 24.) 

Whenever there is ground for suspecting that an 



DISEASES OF THE EYELIDS AND ORBIT. llj 

orbital growth may be of syphilitic origin, mercury 
and potassium iodid should be given a thorough trial 
before resort is had to operation. 

The removal of intraorbital growths, it should be 
remarked, ought to be undertaken only by those 




Fig. 45. — Exenteration of the orbit, with removal of the major part 
of the lids, for epithelioma of the lids and orbit (author's case; photo- 
graph taken two weeks after operation). 



who, in addition to surgical skill, possess thorough 
familiarity with the anatomy of the parts; for, even 
when they seem to be superficial, their extirpation may 
entail invasion of the deeper parts of the orbit, and 
under such circumstances irreparable damage to sight 
may result from awkward manipulation. 



CHAPTER IV. 

DISEASES OF THE LACRIMAL APPARATUS. 

In treating of diseases of the lacrimal apparatus it 
is usual to consider, first, those affections which have 
to do with the lacrimal gland and its ducts, and, second, 
those which pertain to the drainage apparatus, includ- 
ing in this term the puncta, the canaliculi, the lacrimal 
sac, and the nasal, or lacrimal, duct. As, however, 




Fig. 46. — The lacrimal gland, the mouths of its ducts showing; the 
meibomian glands, seen upon the under surface of the lids, and the lac- 
rimal puncta (Nunneley). 

diseases of the lacrimal gland, owing to the protected 
position of the gland and its system of multiple ducts 
(Fig. 46), are of infrequent occurrence, they will be 
treated of very briefly; while, on the other hand, affec- 
tions of the drainage apparatus, since they are common, 
and, as a rule, may be successfully treated by the gen- 
eral practitioner, will be considered at greater length. 



DISEASES OF THE LACRIMAL APPARATUS. II9 

DISEASES OF THE LACRIMAL GLAND. 

Dacryoadenitis, or inflammation of the lacrimal 
gland, occurs as an acute and as a chronic affection. 
Both varieties are rare, though it seems probable that 
acute inflammation of the gland is sometimes mis- 
taken for cellulitis of the orbit, from which it is not 
always easy to distinguish it. It occurs more fre- 
quently in children than in adults and oftener in females 
than in males. It has been known to assume an 
epidemic character, and Galezowski once met with an 
unusual number of cases during an epidemic of mumps. 
Other causes to which it has been ascribed are trau- 
matism, "cold," rheumatism, gout, tuberculosis, syph- 
ilis, gonorrhea, and the extension of inflammation from 
the conjunctiva and cornea. It is usually unilateral, 
but not infrequently both glands are involved. 

Acute dacryoadenitis gives rise to severe pain, which 
may be accompanied by fever, sleeplessness, and de- 
lirium. The lids, the upper lid especially, are greatly 
swollen, and there is marked chemosis of the conjunc- 
tiva, the general appearance of the eye being not unlike 
that which characterizes purulent conjunctivitis (S. 
C. Ayres). Through the enlargement of the gland 
the eyeball may be displaced and its movements re- 
stricted. Palpation of the gland, because of its ex- 
quisite sensitiveness and the swelling of the lid, is 
difficult, and eversion of the lid, to permit of its in- 
spection, is impracticable. Suppuration may supervene 
within a few days, the pus making its way through 
the integument of the lid or into the conjunctival cul- 
de-sac, or the inflammation may subside without the 
formation of pus. 

In chronic dacryoadenitis the enlargement of the 



120 PREVALENT DISEASES OF THE EYE. 

gland may be detected by palpation, and in some 
instances by simple inspection, and upon everting the 
lid the swollen gland may be brought into view as 
a red, tongue-shaped, nodular mass (Hirschberg). 
Though the gland is usually sensitive to pressure, there 
is an absence of the pain, edema of the lids, and con- 
junctival chemosis which characterize the acute variety 
of the disease. Marked displacement of the eyeball, 
usually downward and inward, may occur, and this 
is commonly accompanied by diplopia. 

Treatment. — The treatment of acute dacryoadenitis, 
if the case is seen in its incipiency, should consist in 
the local abstraction of blood by leeches, the application 
of ice-cloths or, if more acceptable to the patient, of 
a lotion of lead acetate and opium (plumbi acetatis, 
gr. xv; ext. opii, gr. x-xv; aq. destil., §iv), and the 
administration of an energetic mercurial purgative, to 
be followed by liberal doses (twenty grains every two 
hours) of sodium pyrophosphate. Should these meas- 
ures fail to cut short the attack, warm fomentations, 
containing opium or belladonna, should be employed, 
and as soon as the presence of pus can be detected it 
should be evacuated by an incision through the in- 
tegument of the lid or through the conjunctival cul- 
de-sac, as may seem to be indicated. 

In chronic inflammation of the gland benefit may 
be expected from the application of mercurial or com- 
pound iodin ointment, combined with the administra- 
tion of potassium iodid or biniodid of mercury. Should 
the gland become so enlarged as to endanger the 
integrity of the eyeball, its extirpation may be neces- 
sary. 

Fistula of the lacrimal gland may occur as a 
sequel of dacryoadenitis or may be of traumatic origin. 



DISEASES OF THE LACRIMAL APPARATUS. 



121 



In rare instances it has been observed as a congenital 
defect. The fistulous orifice is usually situated in the 
upper lid, and much annoyance results from the tears 
which constantly flow from it. 

Treatment. — It is not easy to bring about a healing 
of the fistula, and if this is accomplished it is at the 
risk of precipitating a recurrence of the dacryoadenitis. 
The operative procedure which has proved most effec- 
tual is that suggested by Bowman. Its purpose is to 
convert the annoying, external cuta- 
neous fistula into one opening into the 
conjunctival sac, and, therefore, caus- 
ing little or no inconvenience. A 
needle, attached to a silk thread, is 
passed a short distance into the fistula, 
and is then made to transfix the lid, 
being brought out upon its conjunc- 
tival surface. A second needle, upon 
the other end of the thread, is next 
passed through the lid, close to the 
orifice of the fistula. The two ends are 
then tied tightly, and the thread is left 
to cut its way out. To promote its 
closure, the edges of the external orifice 
of the fistula are freshened. 

Dacryops, or cyst of the lacrimal gland, results 
from occlusion of one or more of the efferent ducts 
of the gland (Fig. 47). It has also been met with as a 
congenital condition. Upon eversion of the upper lid 
the cyst may be observed as a translucent, at times 
lobulated, swelling. Marked distention of the cyst may 
occur from crying. 

Treatment. — This consists in the establishment of 
a permanent opening between the cyst and the con- 




Fig. 47. — Three 
views of the lacrimal 
gland, the efferent 
ducts shown in one 
of them (Nunneley). 



122 



PREVALENT DISEASES OF THE EYE. 



junctival sac. It may be accomplished by excising a 
portion of the cyst-wall and preventing closure of the 
wound by the repeated introduction of a probe, or, as 
suggested by von Graefe, by passing a silk thread 
through the wall of the cyst, tying it in a loop, and 
leaving it to cut its way out. 

Dacryoliths, chalky concretions, occasionally form 
in the lacrimal gland. They are liable to cause me- 




Fig. 48. — Enlargement and prolapse of the palpebral portion of the lacrimal 
gland in an eye with kerato-iritis (de Schweinitz). 



chanical irritation, and, if this happens, they should 
be removed through a conjunctival incision. 

Dislocation of the lacrimal gland, sometimes 
described as hernia or prolapse of the gland (Fig. 48), 
has been met with as a spontaneous condition, and as 
a consequence of injury involving the neighboring parts. 

Treatment. — If possible, the gland should be restored 
to its normal position, and a compress bandage should 
be applied, and worn continuously for some time to 
prevent a redislocation. If this is impracticable, re- 
moval of the gland may become necessary. 



DISEASES OF THE LACRIMAL APPARATUS. I23 

Hypertrophy of the lacrimal gland occurs more 
frequently in children than in adults, and has been 
known to be of congenital origin. The gland may 
become so greatly enlarged as to force the eyeball from 
the orbit, and destroy sight through stretching and 
compression of the optic nerve. Cases have been ob- 
served, however, in which there was marked displace- 
ment of the eye, with great elongation of the optic 




Fig. 49. — Hypertrophy of the lacrimal gland. 

nerve and external ocular muscles, and yet fairly good 
vision and ability to rotate the eye were retained. 

The accompanying illustration (Fig. 49) represents 
a remarkable case of this character, which occurred 
in the practice of the late Prof. Christopher Johnston, 
of Baltimore. The hypertrophied gland, which was 
about the size of a hen's egg, and contained numerous 
dacryoliths, was removed by Dr. Johnston through an 
incision made parallel with the orbital margin. The 
eye subsequently resumed nearly its normal position, 



124 PREVALENT DISEASES OF THE EYE. 

and retained vision equal, at least, to counting 
fingers. 

Treatment. — If the enlargement of the gland is not 
so great as to interfere with vision, an effort should be 
made, by the application of mercurial or compound 
iodin ointment and the administration of potassium 
iodid, to arrest the hypertrophic process. The possi- 
bility that the condition may be of syphilitic origin 
should be borne in mind. If, however, the gland is so 
greatly enlarged as to endanger the integrity of the 
eye, it should be removed without unnecessary delay. 

Removal of the lacrimal gland may be accomplished 
by either of two procedures: The gland may be exposed 
by an incision through the integument of the upper lid 
parallel with the orbital margin, drawn out with a 
tenaculum, and separated from its attachments with 
a knife or scissors. The objection to this method is 
that it involves a more or less complete division of the 
tendon of the levator palpebrae superioris muscle, 
which may result in the production of ptosis. 

The other, and probably better, plan, suggested by 
Velpeau, is to divide the external canthus, evert the 
upper lid, and cut down upon the gland from the 
superior conjunctival cul-de-sac. This method does 
not endanger the integrity of the levator muscle, and 
leaves a less conspicuous scar than the first-described 
procedure. 

Atrophy of the lacrimal gland has been observed 
as one of the late consequences of trachomatous con- 
junctivitis, in the condition known as xerophthalmia. 
Arlt has described a case of this character in which 
the efferent ducts of the gland were obliterated, and 
the gland itself was reduced to one-third its normal 
size. Paralysis of the trigeminus may result in abol- 



DISEASES OF THE LACRIMAL APPARATUS. 125 

ishment of the functional activity of the lacrimal 
gland. 

Tumors of the lacrimal gland are rare, and, not 
infrequently, are of traumatic origin. They are usu- 
ally of slow growth, and occur oftenest in advanced 
life. As they increase in size they interfere with the 
movements of the eyeball, giving rise to diplopia. 
Later they produce exophthalmos, and, eventually, 
may not only destroy sight by pressure upon the optic 
nerve, but may cause death by extension to the brain. 

The following varieties of tumors, believed to have 
had their origin in the lacrimal gland, have been ob- 
served: adenoma, myxoma, myxosarcoma, lympho- 
sarcoma, spindle-cell sarcoma, epithelioma, cylindroma, 
chloroma, and carcinoma. 

Treatment. — Early and complete removal of the 
growth, including, of course, the gland itself, is indi- 
cated. Whether this can be accomplished without 
sacrificing the eye, will depend upon the size of the 
tumor and the extent to which it has invaded the deeper 
parts of the orbit. 

DISEASES OF THE DRAINAGE APPARATUS. 
The lacrimal drainage apparatus (Fig. 50), as has 
been said, is frequently the seat of pathological changes. 
This is due not only to the fact that the mechanism by 
which the tears are carried from the conjunctival sac to 
the nose is complex, and a disarrangement of any one 
of its parts is apt to disturb the normal action of the 
whole, but to the further fact that this apparatus, 
while an appendage of the eye, is, pathologically con- 
sidered, a part, rather, of the nasal passages, and so 
prone to participate in the many maladies to which 
these passages are liable. 



126 



PREVALENT DISEASES OF THE EYE. 



Whatever may be the nature of the pathological 
changes which affect the drainage apparatus, and wher- 
ever they may be located, a common symptom charac- 
terizes them all: the tears are no longer carried, as they 
should be, from the conjunctival sac to the nose, and 
in consequence they overflow the lids, giving rise to the 
annoying condition known as epiphora. This condition 
is not only, in itself, very annoying, but it leads to chronic 




Internal palpebral 

ligament 
Opening of canalicu- 
lus into sac 
Constriction marking 
beginning of bony canal 
Middle concha 



Inferior termination 
of naso-lacrimal 
duct 



Inferior concha 



Fig. 50. — Section showing the course and relations of the lacrimal sac and 
nasal duct (Merkel). 



conjunctivitis, to blepharitis, and, not infrequently, to 
eczema of the lids and cheek. 

Atresia of the lacrimal puncta is met with as a 
congenital and as an acquired anomaly. Congenital 
atresia of the puncta, of which not many authentic 
cases have been reported, may affect one or both eyes, 
and may be attended by absence of the corresponding 
canaliculi. I have encountered one case of this char- 



DISEASES OF THE LACRIMAL APPARATUS. 12/ 

acter, in which, however, but one punctum, with its 
canaliculus, was absent. 

As an acquired condition, complete obliteration of 
the puncta occurs usually as a result of destruction of 
neighboring parts, such as mav happen from burns of 
the lids bv molten metal or lime. It has been known 
also to follow the cicatrization of a smallpox pustule 
and of a chancre of the lid. A superficial occlusion, 
usually of the lower punctum, which is easily overcome, 
and which is due chiefly to desiccation of the parts, 
is often observed in blepharitis marginalis complicated 
bv ectropion. 

Treatment. — The occlusion, whether congenital or 
acquired, may commonly be overcome without much 
difficulty, provided the canaliculus is not absent or 

Fig. 51. — Straight, sharp-pointed probe. 

has not been obliterated. A slight depression usually 
marks the site of the occluded punctum, and at this 
point an opening may be drilled into the canaliculus 
with a straight, rather sharp-pointed probe, such as is 
represented in Fig. 51. After this has been accom- 
plished it is best, as a rule, to slit the canaliculus; 
though it mav be possible to prevent a recurrence of 
the occlusion bv the occasional introduction of a Xo. 2 
or Xo. 3 probe. If the canaliculus as well as the punc- 
tum is obliterated, an opening must be made, starting 
from where the punctum should be, and following the 
usual direction of the canaliculus, into the lacrimal sac. 
For this purpose a sharp-pointed knife is required. 
We shall scarcely succeed, even bv persistent probing. 
in keeping open a considerable part of this artificial 
canaliculus; but, aided by the action of the tears, we 



128 PREVALENT DISEASES OF THE EYE. 

may, at least, be able to establish a permanent opening 
into the lacrimal sac — as I succeeded in doing in the 
case of congenital absence of the punctum and canali- 
culus to which reference has been made — and so get 
rid of the epiphora and the great discomfort to which 
it gives rise. 

Malpositions of the Puncta.— Normally the puncta 
lie in contact with the eyeball, and this position is 
essential to the proper performance of their office. Mal- 
positions of the upper puncta are not common, but 
misplacements of the lower puncta are more frequently 
met with, and usually give rise to greater annoyance. 

Eversion of the puncta is present in most cases of 
ectropion; it occurs also in inflammatory thickening 
of the lid-margin, in senile relaxation of the tissues of 
the lid, and in facial paralysis. Inversion of the 
puncta, which is less frequently encountered, is usually 
a result of entropion. Another faulty position of the 
puncta results from the eye being exceptionally small 
or being deeply set. Under such circumstances a 
triangular space is present, in the neighborhood of 
the inner canthus, between the lids and the eye, and 
in consequence the puncta and the eyeball are not in 
apposition. 

Treatment. — The efficient remedy for all malpositions 
of the puncta is division of the corresponding canalicu- 
lus. This not only relieves the epiphora, but leads to 
the rapid disappearance of the conjunctivitis and the 
blepharitis which are its usual accompaniments. 

Division of the lower canaliculus (the upper canali- 
culus, in my experience, seldom needs to be divided) 
is accomplished most convenientlv with the straight, 
probe-pointed canaliculus knife (Fig. 52), a modifica- 
tion of the beak-pointed knife of Weber (Fig. 53) . Hav- 



DISEASES OF THE LACRIMAL APPARATUS. 



129 



ing previously dilated the punctum and canaliculus by 
the passage of a small probe, the operator, standing be- 
hind the patient, and putting the lid upon the stretch, 
introduces vertically into the punctum the probed tip 
of the canaliculus knife. Then, changing the direction 
of the knife, he passes it horizontally along the canalic- 
ulus until its progress is arrested by the inner wall 



Fig. 52. — Straight, probe-pointed canaliculus -knife. 



Fig. 53. — Weber's beak-pointed canaliculus-knife. 




Fig. 54. — Introduction of canaliculus-knife. 



of the lacrimal sac (Fig. 54). This point having been 
reached, and the edge of the knife being directed upward 
and slightly backward, the lid still being kept well upon 
the stretch, the canaliculus is divided by simply elevat- 
ing the handle of the knife. If the operation is done 
as a step preliminary to the probing of the lacrimal 
duct, the canaliculus should be divided well up to its 
9 



130 PREVALENT DISEASES OF THE EYE. 

juncture with the sac; but if done for some other pur- 
pose, such as eversion of the punctum, it may not be 
necessary to carry the division quite to this point. 

A few instillations of a four per cent, solution of cocain 
renders the operation of division of the canaliculus 
almost painless. As in all operations upon the eye, 
the instruments used should be sterilized by a brief 
immersion in boiling water; after which, to facilitate 
their introduction, it is well to dip the blade of the 
knife and the probes employed into sterilized vaselin. 

The edges of the divided canaliculus, for several 
days, usually show a disposition to grow together, and 
to prevent this they must be separated, once in forty- 
eight hours, by the passage of a greased probe, until 
this disposition is overcome. 

Division of the upper canaliculus, which, as has been 
said, is seldom called for, is accomplished by essen- 
tially the same procedure, except that the operator 
should stand or sit in front of the patient. 

Atresia of the canaliculi may occur as a con- 
genital defect, in association with absence of the puncta, 
as has already been mentioned. It may occur also as 
a consequence of traumatism or of an ulcerative process 
involving the region of the inner canthus. Circum- 
scribed strictures of the canaliculi are of frequent oc- 
currence, especially in connection with stenosis of the 
lacrimal duct. They are usually located near the point 
of juncture of the canaliculus with the lacrimal sac. 

Treatment. — When the canaliculi are completely 
obliterated, their restoration by operative procedure 
is impracticable. It may be possible, however, to make 
an opening directly into the lacrimal sac, and by re- 
peated probings to render it permanently patulous. 
The circumscribed strictures may be overcome by the 



DISEASES OF THE LACRIMAL APPARATUS. I3I 

passage of a small lacrimal probe or with the straight 
probe represented in Fig. 51. If, however, they show 
a disposition to recur, the canaliculus should be slit. 

Dacryoliths, small concretions composed of lime 
and of a fungous growth (leptothrix), occasionally form 
in the canaliculi. Their presence is indicated by a 
circumscribed swelling. As they cause more or less 
irritation, and give rise to epiphora, they should be 
removed without delay. To effect their removal, slit- 
ting of the canaliculus may be required. 

Polypi sometimes form in the canaliculi, and may 
project through the puncta. Their removal may 
necessitate division of the canaliculus. 

Small foreign bodies, eyelashes especially, at times 
find their way into the canaliculi, where they may 
remain for a long time, causing considerable annoyance. 

Treatment. — If they project through the puncta, as 
they usually do, they may be seized with forceps and 
easily withdrawn; otherwise, division of the canaliculus 
may be required to effect their removal. 

Dacryocystitis, or inflammation of the lacrimal 
sac, occurs as an acute and as a chronic affection. 
The former is often spoken of as abscess of the lacrimal 
sac; the latter is usually denominated blennorrhea of 
the sac. 

In the great majority of cases dacryocystitis is secon- 
dary to, and dependent upon, stricture of the nasal 
duct. Primary inflammation of the lacrimal sac, 
that is to sav, inflammation occurring independently 
of stenosis of the nasal duct, though comparatively a 
rare affection, is occasionally encountered. It is met 
with most frequently in the new-born, usually in the 
form of a mild blennorrhea; it is said to occur also 
in strumous children, and it may be brought on by 



132 



PREVALENT DISEASES OF THE EYE. 



external violence or through the entrance into the sac 
of an irritant fluid. 

Blennorrhea of the Lacrimal Sac. — Inflammation 
of the lacrimal sac, secondare to disease ol the nasal 
duct, usually begins as a chronic affection. It is un- 
attended bv pain, and manifests itself chieflv through 
the accumulation of tears and mucus in the sac, their 
regurgitation through the puncta, and the existence 




Fig. 55. — Mucocele; fracture of superior maxilla; exostoses of nasal 
bones (de Schweinitz). 



of epiphora. Frequentlv, there is a perceptible disten- 
tion of the sac {mucocele) (Fig. 55), which, under slight 
pressure with the tip ot the ringer, disappears, the 
contents of the sac regurgitating through the puncta 
and flowing over the front ot the eve, or, exceptionallv, 
it the stenosis ot the duct is incomplete, escaping into 
the nose. 

This state of chronic catarrhal inflammation some- 



DISEASES OF THE LACRIMAL APPARATUS. I33 

times continues indefinitely, without undergoing appre- 
ciable change; but, on the other hand, through the 
influence of "cold," a slight traumatism, the en- 
trance into the sac of a pyogenic organism of unusual 
yirulence, or, as seems to happen not infrequently, 
through the sudden occlusion of the canaliculi at 
their point of juncture with the sac, the inflammation 
is liable at any moment to undergo a sudden and 
acute aggravation. Severe pain, accompanied by 
marked edema and redness of the lids, and often of 
the whole side of the face, comes on; thick, creamy 
pus forms in the sac, and decided evidences of consti- 
tutional disturbance, such as fever, loss of appetite, 
sleeplessness, etc., may manifest themselves. Indeed, 
the local appearance and the general disturbance of 
the system are such as not infrequently to lead to a 
mistaken diagnosis of facial erysipelas. 

These are the symptoms which characterize acute 
dacryocystitis, or abscess of the lacrimal sac 
(Fig. 56"), and which, in many cases of stricture of 
the nasal duct, recur from time to time as long as the 
occlusion of the duct is permitted to remain. 

After several days of intense suffering the integument 
over the sac assumes a yellowish appearance, becomes 
thinned, and, if left to itself, usually gives way at a 
point just below the internal palpebral ligament, per- 
mitting the contents of the sac to escape, and affording 
immediate and almost complete relief from suffering. 
Exceptionally, the inflammation subsides without per- 
foration of the sac, and the pus escapes ultimately 
through the canaliculi and puncta. 

After the contents of the acutely inflamed lacrimal 
sac have been evacuated, either spontaneously or by 
an incision, the inflammation rapidly subsides, and 



J 34 



PREVALENT DISEASES OF THE EYE. 



within ten days or two weeks the opening through 
which the discharge has occurred usually closes, and 
the sac resumes its previous condition of chronic blen- 
norrhea. It may happen, however, that the cicatriza- 
tion of this opening is prevented by the discharge 
through it of tears and muco-pus, and thus there is 
established the troublesome condition known as lac- 




Fig. 56. — Acute dacryocystitis (author's case). 



rimal fistula — a condition which may persist for an 
indefinite period (Fig. 57). 

It is worthy of remark that during an acute attack 
of dacryocystitis it is seldom possible to empty the 
distended sac by pressure, as can usually be done in 
the intervals between such attacks. From this it would 
appear likely that when the sac is unduly distended a 
valve-like closure of the canaliculi at their point of 
juncture with the sac takes place; and it seems not 



DISEASES OF THE LACRIMAL APPARATUS. 



35 



improbable that such an occurrence as this, which 
would necessarily interfere with the previously existing 
drainage of the sac, is often a potent factor in the 
causation of the acute outbreaks. 

Although inflammation of the lacrimal sac, through 
the regurgitation of muco-pus which commonly attends 
it, not infrequently gives rise to inflammation of the 
conjunctiva and cornea, the reverse — the secondary 
involvement of the lacrimal sac in an inflammation 
having its starting-point in the superficial ocular tunics 




Fig. 57. — Lacrimal fistula? — a tear-drop escaping from the fistula on the 
right side (Haab). 



— is an occurrence of extreme rarity. The truth of this 
statement is strikingly illustrated in gonorrheal con- 
junctivitis; for, though the gonococci doubtless find 
their way in great numbers into the lacrimal sac, 
dacryocystitis as a complication of gonorrheal ophthal- 
mia is, so far as I can learn, practically unknown. 

On the other hand, as has already been intimated, 
there is the closest pathological sympathy between the 
drainage apparatus of the eye and the nasal passages, 
and without doubt, in the majority of instances, dacryo- 
cystitis is traceable, directly or indirectly, to nasal disease. 



I36 PREVALENT DISEASES OF THE EYE. 

Treatment. — From what has been said regarding the 
etiology of dacryocystitis — that it is almost invariably 
dependent upon stricture of the nasal duct — it follows 
that a description of the treatment of this affection, or, 
at least, of the chronic variety of it, is practically a 
description of the treatment of stenosis of the nasal 
duct, of which we shall speak presently. It will be in 
place, however, to consider here the treatment of acute 
dacryocystitis. 

It does not often happen that we can cut short an 
attack of acute inflammation of the lacrimal sac; but, 
if the case is seen in its incipiency, an effort should 
be made to accomplish this result. The application of 
a lotion of boracic acid and opium (ext. opii, gr. x-xv; 
acid, boracic, gr. xl; aquae destil., giv), and the ad- 
ministration of an energetic cathartic ("compound 
calomel powder," gr. x), followed by liberal doses of 
sodium pyrophosphate (gr. xx, every two or three hours), 
are the measures which are most likely to prove 
effectual. 

If these measures fail to subdue the inflammation, 
the pad of absorbent gauze, wet with the lotion of 
opium and boracic acid, should be covered with a piece 
of oiled silk or muslin, or rubber protective, to give it 
a poultice-like action (a convenient and cleanly sub- 
stitute for a poultice), and, as soon as it is evident that 
pus has formed, and is endeavoring to make its way 
to the surface, a free incision should be made into the 
distended sac, usually at a point beneath the internal 
palpebral ligament. As such an incision leaves no 
perceptible scar, provided it is made in the direction 
in which the skin tends to wrinkle — that is, from above 
and toward the nose downward and outward — it is 
much better to give the pus free exit in this way than 



DISEASES OF THE LACRIMAL APPARATUS. 137 

to attempt to drain the sac by simply slitting the canalic- 
ulus. After this has been done, and until the discharge 
has lessened markedly, the application of the gauze 
pads should be continued as before. Until all the evi- 
dences of acute inflammation of the sac have disappeared 
no attempt — it should be said with emphasis — ought to 
be made to deal with the stenosis of the nasal duct by 
the introduction of probes or otherwise; for a fresh 
outbreak of dacryocystitis is likely to be the result of 
a disregard of this precaution. 

In chronic inflammation of the lacrimal sac, if for 
any reason treatment of the strictured nasal duct is 
not practicable, a considerable measure of relief may 
be obtained from slitting the lower canaliculus, and 
prescribing a collyrium of mercury bichlorid (i : 12,000 
to 1 : 8000) or of argyrol (5 per cent.) or protargol 
(2 per cent.), to be dropped into the inner corner of 
the eye two or three times a day, explicit instructions 
being given that, before each instillation of the "drops," 
the sac shall be emptied of its contents by pressure 
with the finger-tip. 

It is well to bear in mind that abscesses occasion- 
ally occur in the neighborhood of the lacrimal sac 
(prelacrimal abscess) which, from their appearance 
only, cannot well be distinguished from dacryocystitis. 
However, the history of the case, showing the absence 
of pre-existent lacrimal disease, will usually make the 
diagnosis plain. 

Stricture of the Nasal Duct. — In order to com- 
prehend the etiology of this affection, one needs but to 
call to mind the anatomical and histological peculiar- 
ities of the membranous lining of the duct; to remember 
that it is, at once, a mucous membrane and a periosteal 
membrane; that it contains a dense plexus of veins,. 



138 PREVALENT DISEASES OF THE EYE. 

resembling those of the turbinate bodies; and that 
here and there it is thrown into valve-like folds, which 
encroach considerably upon the lumen of the canal. 
In the presence of such conditions it is evident that 
even a trivial inflammation occurring here is liable to 
cause, at least, a transient occlusion of the duct; and, 
further, it is manifest that, though the inflammation 
may begin as a simple catarrhal process, involving only 
the mucous membrane, it is apt, if it be prolonged or 
become more intense, to extend to the underlying fibrous 
tissue, and so develop into an actual periostitis. Thus 
it happens that the transient occlusion of the duct 
caused by edema of the mucous membrane and en- 
gorgement of the underlying venous plexus, which 
under favorable circumstances passes away without 
leaving any permanent ill effects, may give place to 
a persistent stenosis, dependent upon periosteal and 
osteal thickening. 

Again, if we would understand how it is that the 
conditions which favor such permanent occlusion of 
the nasal duct occur as often as they do, we have but 
to recall the fact, to which reference has already been 
made, that this canal, although an appendage of the 
eye, is in reality a part rather of the nasal cavity into 
which it opens, and that its relation to this cavity, 
prone as it is to inflammatory affections, is as close 
pathologically as it is anatomically. 

Watering of the eyes, as is well known, is a usual 
symptom of acute rhinitis, and it is probable that in 
pronounced cases of this affection the mucous membrane 
lining the lacrimal drainage apparatus commonly parti- 
cipates, to a greater or less degree, in the catarrhal pro- 
cess. With the subsidence of the rhinitis the lacrimal 
symptoms usually disappear, and the parts return to their 



DISEASES OF THE LACRIMAL APPARATUS. I39 

normal condition. Exceptionally, however, because of 
the greater intensity of the inflammation, the occurrence 
of a second or third attack before the first has been 
recovered from, a congenital narrowness of the duct, 
or a peculiar susceptibility of the lacrimal passages to 
disease (a susceptibility which, not infrequently, is 
inherited), the inflammation of the lining membrane 
of the duct does not subside with the nasal affection, 
but assumes the more serious character which has just 
been described. 

In this way, and, perhaps, still more frequently from 
the extension of chronic inflammatory affections of the 
nose to the lacrimal passages, stricture of the nasal 
duct, which, as has been said, is the usual forerunner 
of dacryocystitis, commonly arises. 

The nasal affections of inherited and of acquired 
syphilis, it should be remarked, are especially liable 
to involve the lacrimal apparatus. Gummata have 
been met with in the lacrimal sac, as well as in the 
duct. Tuberculosis of the nose, through extension to 
the lacrimal passages, has been known to cause occlu- 
sion of the nasal duct. The exanthematous fevers also 
may lead to this condition, as a consequence of the 
inflammation of the nasal mucous membrane which 
attends them; and, it may be added, not only inflam- 
mation of the lacrimal sac, as has been indicated, but 
stricture of the duct is occasionally brought about by 
a blow upon the bridge of the nose or in the region 
of the inner canthus. 

As to the location of the strictures, although their 
most common situation is at the upper extremity of 
the duct, there is no part of the canal in which they 
are not frequently encountered. Multiple strictures, at 
least in cases of long standing, are the rule. As they 



I4O PREVALENT DISEASES OF THE EYE. 

are the outcome of periosteal inflammation, the stric- 
tures are almost always, in part at least, of bony struc- 
ture. In form they may be circumscribed and annular 
(a thin bony septum being occasionally met with) or 
ill defined and of wide extent, involving a considerable 
part of the length of the canal. A stricture located 
at the lower extremity of the duct, it is well to bear in 
mind, is more easily overlooked; and it may happen 
that a mistake of this character will render of no avail 
a course of treatment which otherwise would prove 
successful. 

Treatment. — Of the many ingenious surgical pro- 
cedures for dealing with occlusion of the nasal duct 
which have been suggested from time to time, there are 
but very few which have for us, at the present day, 
an interest that is other than historical. 

The invaluable suggestion of Bowman (1857) that 
the canaliculus should be slit as a preliminary step to 
the treatment of stenosis of the nasal duct may be said 
to mark the beginning of a new era in the surgery of the 
lacrimal apparatus. The great merit of this procedure 
is that it renders possible the use of lacrimal probes 
sufficiently large to completely obliterate the strictures, 
and restore the normal caliber of the canal. It was not, 
however, until some years after Bowman's operation was 
generally adopted that the opportunity which it affords 
in this respect was fully appreciated and taken advan- 
tage of; but, when this finally came about, the treat- 
ment of lacrimal strictures ceased to be what it previ- 
ously had been — an opprobrium of ophthalmic surgery. 

Dr. E. Williams, of Cincinnati, and Dr. H. D. 
Noyes, of New York, were the first to realize the in- 
adequate size of the probes employed by Bowman and 
his followers, and to urge the necessity of using probes 



DISEASES OF THE LACRIMAL APPARATUS. I4I 

of considerably larger caliber. A brief experience in 
the treatment of diseases of the lacrimal apparatus led 
me to a similar conclusion, and induced me (in 1877) 
to undertake the measurement of a large number of 
nasal ducts (in the dried skull and in the cadaver) 
with a view to determining the usual size of the duct, 
and how large a lacrimal probe it would be practi- 
cable, and probably advantageous, to employ.* 

As a result of these measurements (Fig. 58), I devised 
the series of probes — sixteen in number, the smallest 

4 Bowman's largest, No. 6, probe; diameter = 1.50 mm. 

^P Author's largest, No. 16, probe; diameter = 4 mm. 

• Average size of 10 adult nasal ducts, cadaver; diameter = 
4.47 + mm. 

^^k Largest of 10 adult nasal ducts, cadaver; diameter = 5.25 mm. 



Largest of 7c bony nasal ducts; diameter = 7 mm. 

Fig. 58. — Diameters of probes, and of nasal ducts as determined by 

author. 

size, No. 1, having a diameter of 0.25 of a millimetre, 
and each number increasing in size by 0.25 of a milli- 
metre, so that the largest, No. 16, has a diameter of 4 
mm. — which I have used since with great satisfaction, 
and which are now quite generally employed. The ac- 
companying illustration (Fig. 59) represents the actual 
size of No. 15 and No. 16, the largest probes of the 
series, and shows the correct shape of the tips and the 
curve which experience has shown to be most convenient. 

* "The Use of Large Probes in the Treatment of Strictures of 
the Nasal Duct," "Trans, of the Medical and Chirurgical Faculty 
of Maryland," 1877, p. 154. 



1 4 2 



PREVALENT DISEASES OF THE EYE. 



Although other ways of treating strictures of the 
nasal duct are advocated, such as dividing them with 
a suitably shaped knife,* inserting styles, etc., their 



L 



16 



Fig. 59. — Author's lacrimal probe. 



Fig. 60.— Dr. N. R. Smith's 
knife for dividing strictures of the 
nasal duct (Norris and Oliver). 



* This plan of treatment was first practised (in 1846) by my 
grandfather, the late Prof. Nathan R. Smith, of Baltimore, who 
devised a knife of peculiar pattern for the purpose (Fig. 60). Many 
years afterward it was revived, improved upon, and brought more 
prominently into notice by Stilling, of Cassel. (See the author's ar- 
ticle upon "Diseases of the Lacrymal Apparatus" in Norris and 
Oliver's "System of Diseases of the Eye," Vol. III.) 



DISEASES OF THE LACRIMAL APPARATUS. I43 

thorough dilatation by means of probes sufficiently 
large for the purpose is the method which, in my opin- 
ion, yields by far the best results, and which I unhesi- 
tatingly commend to others. 

Unquestionably there are cases of stenosis of the 
duct, especially such as are associated with and de- 
pendent upon severe chronic nasal disease, that are 
not amenable to any plan of treatment; but such cases 
are rare, and, apart from these, the dilatation treatment 
with large probes, if systematically carried out, com- 
monly yields most gratifying results, a complete and 
permanent cure, even in cases of long standing, being 
its usual outcome. 

Briefly described, the method of dealing with stric- 
tures of the nasal duct which long experience has led 
me to place such confidence in is as follows: 

Cocain (4 per cent, solution) or holocain (1 per cent, 
solution) having been instilled several times into the 
inner corner of the eye, and, alternating with these in- 
stillations, several applications of adrenalin solution 
(1 : 1000) having been made, a No. 2 probe, or a No. 1 
followed by a No. 2, is passed through the lower canali- 
culus into the sac, for the double purpose of slightly 
dilating the punctum and canaliculus and of discovering, 
and, if possible, overcoming, any stricture which may 
exist at this point. If a stricture too firm to be over- 
come by either of these probes is encountered (the usual 
site of such strictures being at the juncture of the 
canaliculus with the lacrimal sac) the straight, sharp- 
pointed probe (Fig. 51) is substituted, and with a drill- 
like motion the obstruction is penetrated. This pre- 
liminary probing I regard as important, as it insures the 
complete division of the canaliculus which is to follow. 

In the manner already described (p. 128) and with 



i 4 4 



PREVALENT DISEASES OF THE EYE. 



the straight, probe-pointed knife (Fig. 52) the canali- 
culus (always the lower canaliculus) is now divided 
well up to its juncture with the sac. The next step is 
the passage of the probe through the occluded nasal 
duct, as large a probe being used as can be readily 
introduced into the sac through the divided canaliculus. 
This is usually a No. 5, exceptionally a No. 6, probe. 
In passing the probe I prefer, as in dividing the canal- 
iculus, to stand behind the patient, using the right hand 
for the right eye and the left hand 
for the left eye, because the patient's 
head can be more easily steadied in 
this position, and because, more- 
over, it is more convenient for the 
operator. 

The probe selected, which pre- 
viously has been sterilized by brief 
boiling, and anointed with sterile 
vaselin, is passed in the usual way, 
first, horizontally, along the divided 
canaliculus, the lid being kept upon 
the stretch with the thumb of the 
opposite hand, until its point has 
entered the sac and come in contact 
with its inner wall; then it is turned into a vertical posi- 
tion, and passed slowly through the duct until it reaches 
the floor of the nose (Fig. 61). Provided the probe 
has entered fairly into the lacrimal sac, any reasonable 
amount of force that may be required to pass it through 
the occluded duct is considered permissible, care, of 
course, being exercised that it does not take a wrong 
direction. The probe is withdrawn after having been 
allowed to remain in the duct for from ten to twenty 
minutes. 




Fig. 61. — Introduction 
of lacrimal probe. 



DISEASES OF THE LACRIMAL APPARATUS. I45 

If, as sometimes happens, neither a No. 5 nor a 
No. 4 probe can be made to enter the sac directly after 
the division of the canaliculus — an indication that there 
is an undivided constriction at the juncture of the 
canaliculus and the sac, or that the point of the probe 
has caught in the freshly cut tissues — an attempt is 
made to dilate the constriction by means of the "sup- 
plementary probe" (Fig. 62), which was devised to 
meet this particular condition.* 

If this attempt also fails, if even the slender tip of 
this probe cannot be made to enter the sac, an interval 
of fortv-eight hours is allowed to elapse without further 
effort; when the difficulty previously encountered will 




Fig. 62. — Author's supplementary lacrimal probe (about two-thirds ac- 
tual size). 

often be found in great measure to have disappeared. 
Should this not prove to be the case, an opening is drilled 
through the constriction with the straight, sharp probe 
(Fig. 51), or a No. 5 probe is passed along the 
divided canaliculus to the point of resistance, the lid 
being kept well upon the stretch, and is then turned 
vertically and forced through the obstruction — a pro- 
cedure, however, which it is desirable to avoid, as it 
may result in making a false passage from the canalicu- 
lus directly into the duct. Exceptionally, it is found 
necessary to divide the constriction with a sharp-pointed 
knife, for which purpose a narrow-bladed Sichel cataract 
knife has been found especially convenient. 

*"Trans. American Ophthalmological Society," 1901, p. 398. 



I46 PREVALENT DISEASES OF THE EYE. 

During the early stages of the treatment the probing 
is repeated every other day, usually a size larger probe 
being passed each time. Occasionally, if the probe 
last introduced was passed very easily, a size is skipped, 
while, on the other hand, the same probe is passed 
more than once, if found to be tighter than usual. 

The size of the largest probe which it is desirable 
to use varies, of course, in different cases, but it is 
seldom best to stop short of No. 14; for it is to be 
borne in mind that the end in view is not simply the 
making of a small opening through the strictures, as 
was formerly done with such unsatisfactory results, 
but their complete obliteration, and the restoration 
of the normal caliber of the duct, since it is only in 
this way that frequent relapses are to be avoided and 
permanently good results assured. In about two- 
thirds of the cases, including those occurring in children 
as well as those in adults, the No. 16 probe is used. 

In passing the larger probes considerable force is 
sometimes employed. Experience has shown not only 
that this is permissible, but that, instead of being 
harmful as many maintain it must be, the effect upon 
the carious walls of the duct is distinctly beneficial, 
the result being not unlike that produced by the 
curetting of diseased bone in other parts of the body 
(Fig. 63). 

When as large a probe has been introduced as is 
deemed advisable, the interval between the probings 
is gradually increased, first to three or four days, then 
to a week, a fortnight, and finallv to a month or two 
months; and when several of these longer intervals 
have elapsed, without any tendency to recontraction 
having manifested itself, the case is dismissed with 
full assurance that a permanent cure has been effected. 



DISEASES OF THE LACRIMAL APPARATUS. 



147 



Including these longer intervals, the treatment fre- 
quently extends over a period of eight or ten months; 
but the active treatment, involving the frequent prob- 
ings, is comprised within as many weeks. 

The improvement occurs much more rapidly in some 
cases than in others, so that the length of time during 
which it is necessary to use the probes varies consider- 
ably. It is a safe rule not to discontinue the treatment 
as long as there is any dacryocystitis or any roughness 
of the walls of the duct noticeable upon passing the 




Fig. 63. — Position of lacrimal probes introduced through lower canaliculus. 

probe. However, as it sometimes happens that the 
inflammation is kept up by the too frequent use of 
the probe, it is well, in obstinate cases, to try the effect 
of lengthening the interval between the probings. 

When an attempt is made to pass a probe after the 
lapse of six or eight weeks, it is sometimes found diffi- 
cult or impossible, owing to a contraction having oc- 
curred at the juncture of the canaliculus and the sac, 
to introduce the size which was previously employed. 
When this happens, the constriction is dilated by means 



I48 PREVALENT DISEASES OF THE EYE. 

of the "supplementary probe" (Fig. 62), after which 
the probe previously used may commonly be passed 
without difficulty. 

No attempt is made to inject with a syringe anti- 
septic or other solutions into the lacrimal sac. Instead, 
a collyrium is prescribed, which the patient is instructed 
to drop into the inner corner of the eye three times a 
day, after having previously pressed out the contents 
of the sac with the finger-tip. The collyrium which 
has been found most useful for this purpose is a solution 
of bichlorid of mercury (1 : 12,000 to 1 : 8000) with 
the addition of sodium chlorid (1 per cent.). A solu- 
tion of alum and boracic acid (alum., gr. j-ij; acid, 
boracic, gr. x; aquae destil., gj) has also given good 
results, and so has a weak solution (2 per cent.) of 
protargol. 

The presence of a lacrimal fistula, even when ac- 
companied by caries of the underlying bone, has not 
seemed to call for special treatment, beyond the 
snipping off, or cauterization with silver nitrate, of 
exuberant granulations, if they happen to be present; 
for it has been found that, as soon as thorough drainage 
has been established by the passage of the large probes, 
the fistula heals, and the carious bone, taking on a 
healthier action, becomes re-covered with periosteum. 

The frequent dependence of disease of the lacrimal 
apparatus upon nasal catarrh is kept in mind, and 
whenever it seems to be indicated treatment is directed 
to the nose. A solution of bichlorid of mercury, sodium 
chlorid and glycerin (hydrarg. bichlorid., gr. ss; sodii 
chlorid., gr. xv; glycerin., oSs; aquae destil., givss) 
applied to the nose three times a day, by means of a 
hand atomizer, has been found especially useful under 
such circumstances. Constitutional treatment is occa- 



DISEASES OF THE LACRIMAL APPARATUS. I49 

sionally called for, more especially when the lacri- 
mal affection is dependent upon inherited or acquired 
syphilis or upon struma. Ammonium chlorid, in ten- 
grain doses, has been found beneficial, more particu- 
larly when nasal catarrh is present. 

When patients from a distance are unable to remain 
under treatment as long as is thought desirable, it has 
been found practicable, after the duct has been thor- 
oughly dilated, to teach them to introduce the probes 
themselves. In this way relapses, which might have 
occurred from a too early discontinuance of the treat- 
ment, have been avoided. The probe represented in 
Fig. 64 (usually made to correspond in size with No. 




Fig. 64. — Author's lacrimal probe for use by patients (actual size). 

13) was devised for this purpose, and has proved very 
useful. 

Electrolysis has been tried to a limited extent, in 
connection with the large probes, to hasten the obliter- 
ation of the strictures, but its effect was inappreciable. 

In intractable cases of stenosis of the nasal duct, 
accompanied by persistent dacryocystitis, which have 
failed to yield to less radical measures, removal of the 
lacrimal gland, and also excision of the lacrimal sac 
or its destruction by means of caustics or by means 
of the galvanocautery or thermocautery, are practised 
by some surgeons, and, it is claimed, with excellent 
results. I have had no experience with these pro- 
cedures, and have seldom encountered cases in which 
they seemed to be demanded. As to the use of styles, 



15O PREVALENT DISEASES OF THE EYE. 

which some authorities still commend, I abandoned 
them, after a thorough test of their merits, many years 
ago, because the good which they accomplished proved, 
in almost every instance, to be but temporary. 

In the transient occlusion of the nasal duct which 
commonly accompanies the dacryocystitis of the new- 
born, previously referred to, operative treatment is 
seldom called for, since the blennorrhea of the sac and 
the epiphora usually disappear as a result of the use 
of one of the collyria which have been spoken of 
(bichlorid of mercury, alum and boracic acid, or pro- 
targol). Should this, after persistent trial, not prove 
to be the case, however, the canaliculus should be 
divided, and the duct probed. The outcome of this 
treatment is usually very satisfactory, and it is seldom 
necessary to repeat the probing oftener than five or 
six times. In a case of this character which was oper- 
ated upon when the child was fifteen months old, a 
No. 12 probe was passed without difficulty, and a 
complete cure was soon effected. 



CHAPTER V. 
DISEASES OF THE CONJUNCTIVA. 

There are no diseases of the eye with which it is 
more important that the general practitioner should 
be familiar than those which have to do with the con- 
junctiva. This is true not only because they are of 
very common occurrence, and it must needs happen 
that he will often be called upon to treat them; but 
because it is frequently impracticable for him to refer 
such cases to the specialist, and because, moreover, 
there is, in most instances, little reason why he should 
not himself be able to deal with them successfully. 

As has already been intimated, the usual shortcoming 
of the general practitioner in dealing with diseases of 
the conjunctiva is in the direction of faulty diagnosis; 
for the indications for treatment are commonly clear 
when once a correct diagnosis has been reached. It 
is of the first importance, therefore, that he should be 
able not only to distinguish conjunctival inflammation 
from inflammation of the deeper structures of the eye, 
but to recognize the several varieties of conjunctivitis, 
since the treatment which they call for is essentially 
different. 

The medical practitioner unfamiliar with diseases 
of the eye will be saved, at least, a goodly number of 
the diagnostic errors into which he is apt to fall, if 
he will bear in mind that, speaking broadly, inflamma- 
tion of the conjunctiva is not accompanied by severe 
pain or pronounced photophobia; that it is attended 

151 



152 PREVALENT DISEASES OF THE EYE. 

by more or less abundant secretion of mucus or muco- 
pus; that it does not appreciably impair sight, except 
through the presence of this discharge, or through 
implication of the cornea, as in purulent or tracho- 
matous conjunctivitis; that the vascular injection which 
attends it is made up largely of coarse, superficial, 
movable vessels, which run irregularly in all directions; 
that the injection is brick-red in color, and that the 
redness is not confined to, or especially marked in the 
neighborhood of, the corneal border; and if he will 
remember, on the other hand, that the presence of 
severe pain, accompanied usually by photophobia and 
lacrimation, and by more or less pronounced obscura- 
tion of vision, and attended by pericorneal injection, 
pinkish in color, and composed of fine, immovable, 
subconjunctival vessels, points unmistakably either to 
corneal inflammation or to inflammation of the deeper 
structures of the eye, such as iritis, cyclitis, glaucoma, 
etc. 

Again, in the matter of ocular therapeutics, he will 
have made a long stride in the right direction, if he 
will further bear in mind that in the treatment of 
conjunctival inflammations, as well as of other inflam- 
mations of the eye, severe remedies — applications which 
cause pain and which increase photophobia and lacri- 
mation — are, almost without exception, contraindicated. 

In the account about to be given of the more preva- 
lent affections of the conjunctiva the difficulties with 
which the general practitioner has to contend in the 
matter of differential diagnosis will be kept in mind, 
and every effort will be made to afford him assistance 
in this direction. The suggestions regarding treatment 
will also be made as definite and concise as practicable. 

Hyperemia of the Conjunctiva. — Hyperemia of 



DISEASES OF THE CONJUNCTIVA. 1 53 

the conjunctiva, when pronounced, is usually accom- 
panied by some discomfort of the eyes — a sensation of 
burning or itching — and by undue lacrimation. It 
occurs as a transient and also as a chronic condition. 

Transient or acute conjunctival hyperemia may 
arise from a variety of causes, and, as a rule, is a 
matter of but little moment. The presence of a 
foreign bodv upon the cornea or conjunctiva, exposure 
of the eyes to a strong wind, to undue heat or light 
or to irritant gases, prolonged use of the eyes, espe- 
cially with imperfect illumination, crying, etc., are 
some of the causes which may give rise to it. It also 
marks the onset of most superficial inflammations of 
the eye, and is a frequent accompaniment of acute 
rhinitis and of facial neuralgia. 

Chronic hyperemia of the conjunctiva, a condition 
of greater significance, is more frequently due to eye- 
strain, the result of errors of refraction or anomalies 
of the ocular muscles, than to any other one cause. It 
may be dependent also upon chronic rhinitis, inflam- 
mation of the lacrimal passages, trichiasis, alcoholism, 
and gout. 

In the treatment of this condition the most important 
consideration is the removal of the cause. In chronic 
hyperemia the refraction and the muscular balance of 
the eyes should be examined, and glasses should be pre- 
scribed if found to be indicated. Nasal or lacrimal 
disease, if present, should be treated, and measures 
should be taken to combat any disorder of the system, 
such as a gouty diathesis, which might be a factor in 
the causation of the local affection. As supplementary 
measures, a collyrium of boracic acid (acid, boracic, gr. 
x; aq. destil., 5j) or of boracic acid and sulphate of 
zinc (zinci sulphat., gr. \\ acid, boracic, gr. x; aq. 



154 PREVALENT DISEASES OF THE EYE. 

destil., 5j), to be dropped into the eyes three times a 
day, and, especially in acute cases, the application to 
the lids of cold water or ice-cloths, are useful. 



CONJUNCTIVITIS. 

Whether regarded from a clinical or a pathological 
point of view, all of the commonly recognized types of 
conjunctivitis may very properly, and with practical 
advantage, be classified as follows: First, catarrhal or 
simple conjunctivitis; second, purulent or gonorrheal 
conjunctivitis; third, croupous or membranous con- 
junctivitis; fourth, diphtheritic conjunctivitis; fifth, 
follicular conjunctivitis; sixth, trachomatous or granu- 
lar conjunctivitis; seventh, vernal conjunctivitis or 
spring catarrh; and, eighth, phlyctenular or scrofulous 
conjunctivitis. 

As a rule, it is not difficult to differentiate these 
several varieties, which, though they possess certain 
features in common, exhibit other well-marked and 
distinctive characteristics; but, occasionally, the most 
experienced observer may find himself at fault in this 
respect, being unable to determine, simply from in- 
spection of the eye, to which class a particular case 
should be assigned. However, the history of the case, 
and especially its behavior under treatment, will usu- 
ally dispel any doubt upon this point. With the ex- 
ception of phlyctenular conjunctivitis and of diph- 
theritic conjunctivitis, all of these different types of 
conjunctival inflammation are essentially local dis- 
orders. As regards their etiology, much has yet to 
be learned, though considerable progress has been 
made in this direction within the past few years. 

Catarrhal or Simple Conjunctivitis.— This variety 



DISEASES OF THE CONJUNCTIVA. 155 

of inflammation of the conjunctiva, which is of very 
common occurrence, is met with as an acute, and, less 
frequently, as a chronic, affection. 

In a well-marked attack of acute catarrhal conjunc- 
tivitis the patient complains of a sensation as though 
sand were in the eyes, exhibits some little dread of 
light, and, upon being questioned, commonly states 
that his eyes smart when he attempts to read or write, 
that after sleep the lashes are stuck together by dis- 
charge, and that during the day some discharge col- 
lects about the inner cornea of the eyes and upon the 
lid-margins, and requires to be wiped away from time 
to time. Upon inspection, the lids will be found to 
be somewhat edematous, and the bulbar conjunctiva 
to be markedly injected and of a nearly uniform brick- 
red color, the injected blood-vessels being superficial, 
coarse, tortuous, and movable. The palpebral con- 
junctiva also will be congested and somewhat swollen, 
and strings of mucus will be discovered upon the inner 
surface of the lids and in the retrotarsal folds. The 
cornea and iris present a normal appearance, and the 
pupil responds to light as in health (Plate III, Fig. 1). 

In the milder cases, which are the more common, 
the lids are not edematous, and the bulbar conjunctiva 
is but slightly, if at all, injected, the evidences of in- 
flammation being limited to the palpebral conjunctiva 
and to the retrotarsal folds, the diagnosis, under such 
circumstances, being based mainly upon the appearance 
of the inner surface of the lids, the sudden onset of 
the attack, and the gumming of the eyelashes during 
sleep. Another feature of acute catarrhal conjunc- 
tivitis, which is of decided diagnostic value, is that it 
is essentially a binocular affection. One eye, it is true, 



^A 



I56 PREVALENT DISEASES OF THE EYE. 

is often attacked before the other, but within twenty- 
four hours both eyes are sure to be affected. 

A variety of phlyctenular conjunctivitis — the ca- 
tarrhal type — very closely resembles acute catarrhal 
conjunctivitis; but as this affection is usually monocu- 
lar, and is commonly accompanied by blepharitis, 
eczema of the lids or face, or other signs of constitu- 
tional disorder, it is not difficult, as a rule, to recognize 
its true character. The character of the conjunctival 
injection, the absence of changes in the cornea or iris, 
the normal size and reaction of the pupil, and the non- 
existence of pain suffice to differentiate the disease 
under consideration from inflammation of the cornea 
or iris and from inflammatory glaucoma. As the 
symptoms produced by the presence of a foreign body 
upon the cornea or beneath the upper lid very closely 
resemble those of a commencing conjunctivitis, one 
should be careful to avoid falling into a diagnostic 
error of this character. 

Acute catarrhal conjunctivitis, which occasionally 
assumes an epidemic character, and under such cir- 
cumstances is popularly known as "pink eye," is 
unquestionably, though not markedly, contagious. As 
to its etiology, there can be no doubt that in most 
instances it is of bacterial origin. "Cold" probably is 
at times a factor in its causation; but doubtless acts 
chiefly by rendering the conditions more favorable 
for the development of the invading bacteria. The 
Weeks bacillus and the pneumococcus are the micro- 
organisms which are most frequently concerned in its 
production. 

Under favorable hygienic conditions the disease is 
usually self-limited, and disappears within ten days 
or a fortnight; but occasionally, when neglected, it 



DISEASES OF THE CONJUNCTIVA. 157 

runs a protracted course, lasting, perhaps, for many 
weeks. 

Treatment. — The treatment of this variety of con- 
junctivitis, which has proved so efficacious that I 
seldom have occasion to employ other measures, con- 
sists in the use of a collyrium of zinc sulphate and 
boracic acid (zinci sulphat., gr. ss; acid, boracic, gr. 
x; aq. destil., 5j), which is dropped into the eyes three 
times a day, and the application of a bland ointment 
to the lids at bed-time. For this latter purpose "cold- 
cream," to which boracic acid may be added in the 
proportion of five grains to the dram, is well adapted. 
When the eyes are more than usually irritable and 
uncomfortable, relief is afforded by the application to 
the lids of pads of absorbent gauze wet with a lotion 
of opium and boracic acid (ext. opii., gr. x; acid, 
boracic, gr. xl; aq. destil., Siv). In the event of this 
treatment not proving promptly efficacious, a weak 
solution of argyrol (5 per cent.) or protargol (2 per cent.) 
may be substituted for the zinc and boracic acid, being 
dropped into the eves three times a day. 

Chronic catarrhal conjunctivitis, which, as has been 
said, is less common than the acute type, owes its 
chronicity, as a rule, to some extraneous cause. Among 
the conditions that may give rise to it may be men- 
tioned accommodative strain, disease of the lacrimal 
apparatus — especially when attended by blennorrhea 
of the lacrimal sac — partial ectropion, chronic rhinitis, 
unfavorable hygienic surroundings, as in crowded re- 
formatories, etc., and habitual exposure of the eyes to 
irritating gases or to heat and dust. The conjunctival 
injection and discharge may be, but usually are not, 
pronounced. 

Treatment. — The collyrium of zinc sulphate and 



I58 PREVALENT DISEASES OF THE EY,E. 

boracic acid, as recommended in the acute form of the 
disease, is the most efficacious local remedy; but of 
greater importance is it to discover, and, if possible, 
to eliminate, the condition upon which the affection 
depends. Any refractive or muscular anomaly found 
to be present should be corrected by the careful adjust- 
ment of glasses; disease of the lacrimal apparatus or 
of the nose, if it exists, should receive attention; the 
canaliculus should be slit, if there is eversion of the 
punctum; and the patient's surroundings and his 
occupation, if thev are such as to favor the continu- 
ance of the disease, should, if possible, be changed for 
the better. Good food and tonics — iron, quinin, and 
strychnin, especially — by building up the system will 
often accomplish much. 

Purulent or Gonorrheal Conjunctivitis. — This 
severe type of conjunctival inflammation is met with 
in the new-born — the so-called ophthalmia neonatorum 
— as a result of infection of the eyes during the passage 
of the child's head through' the vagina, and in later 
life in consequence of accidental inoculation of the 
eyes with gonorrheal discharge from a specific urethri- 
tis or vaginitis, or from a previously infected eye. 
The purulent conjunctivitis of the infant and the 
gonorrheal ophthalmia of the adult are, therefore, 
essentially one and the same disease, each being due 
to inoculation of the conjunctiva with the gonococcus. 
(See Plate II, Fig. 1.) 

In purulent conjunctivitis the inflammation is much 
more intense than in catarrhal conjunctivitis. The 
discharge, which is thick and creamy and distinctlv 
purulent, is very profuse, so that it overflows the lids, 
and runs down upon the cheek. The lids are greatly 
swollen, often of a dusky red color, and so tense that 



PLATE II. 



FlG.I 



fio.e 






■% 



•a. 






Fig.M 



P--W& 



3*6 



v: 



* 



#«•* 



<& 



Fig. I. — Discharge from Right Eye in a Case of Purulent Con- 
junctivitis; Gonococci Numerous in Cells (Stephenson). 

Fig. II. — Bacillus of Weeks in Pure Culture (from a Photo- 
graph) (Weeks). 

Fig. III. — Conjunctival Secretion from Acute Contagious Con- 
junctivitis; POLYNUCLEAR LEUKOCYTES WITH THE BACILLUS OF WEEKS J 

P, Phagocyte Containing Bacillus of Weeks; Immers. t V, Oc. iii 

(MORAX). 

Fig. IV. — Secretion from a Case of Conjunctivitis, Showing 
Pneumococci; Immers. t V, Oc. iii (Morax). 



DISEASES OF THE CONJUNCTIVA. 159 

it is usually impossible to evert them (Plate III, Fig. 
2). The bulbar conjunctiva is intensely injected, and 
so chemotic that it overlaps the cornea, and may even 
hide it completely from view. 

As a rule, in ophthalmia neonatorum the disease runs 
a less malignant course, and the prognosis is less grave, 
than in the adult. This, it would seem, is largely because 
of the fact that the discharge which infects the eyes of 
infants is seldom due to a recently acquired gonorrhea, 
whereas in adults the inoculation is more apt to occur 
during the height of the urethritis or vaginitis, when 
the infectious power of the discharge is greatest. Apart 
from this, however, it would appear that the eyes of 
the new-born are capable of withstanding gonorrheal 
infection better than are those of adults. The interval 
between the inoculation of the eye and the appearance 
of the first signs of the disease — which at the outset 
are much like those of a well-marked attack of acute 
catarrhal conjunctivitis — is somewhat greater in the 
infantile than it is in the adult form of the affection, 
the incubation period in the latter being from twelve 
to fortv-eight hours, whereas in the former it is usually 
from forty-eight to seventy-two hours. In ophthal- 
mia neonatorum (Fig. 65) both eyes are usually affected, 
because each is almost sure to be inoculated with the 
vaginal discharge; in adults, on the other hand, the 
disease is commonly monocular, though there is always 
great danger that the second eye may become affected 
through the transference of discharge from the one first 
involved. 

The disease runs a tedious course, and, even when 
promptly and carefully treated, is seldom cured under 
four to six weeks. Severe pain, marked photophobia, 
and lacrimation characterize the height of the attack. 



i6o 



PREVALENT DISEASES OF THE EYE. 



The great danger to be feared, in both forms of the 
disease, is necrosis of the cornea (Fig. 66). This 
probably results, not infrequently, from a secondary 
infection; but it is due, primarily, to the nutri- 
tion of the cornea being seriously interfered with 




Fig. 65. — Purulent (gonorrheal) conjunctivitis in the new-born (Haab). 




Fig. 66. — Extensive necrosis of the cornea (Ramsay). 



through the intensity of the conjunctival inflammation. 
Complete destruction of the cornea, which is by no 
means uncommon, necessarily involves loss of useful 
vision; but, if the destruction is not complete, a 
considerable amount of sight may be regained, either 




PLATE III. 



Fig. i. — Acute Catarrhal Conjunctivitis. 





Fig. 2. — Purulent Conjunctivitis (Gonorrheal). 



M 




s/fcioUU 



Fig. 3. — Acute Trachomatous Conjunctivitis (Papillary Variety). 



DISEASES OF THE CONJUNCTIVA. l6l 

with or without the help of an iridectomy. When the 
discharge, instead of being thick and creamy, is thin 
and watery, and is accompanied by a membranous 
exudation upon the surface of the palpebral or bulbar 
conjunctiva and by a plastic infiltration into the sub- 
conjunctival cellular tissue, the prognosis is distinctly 
unfavorable, and the danger of corneal complications 
very much greater. 

Although more tractable than the adult form of 
the disease, ophthalmia neonatorum, because its 
treatment is so often neglected, is the most fruitful 
source of incurable blindness. According to the sta- 
tistics gathered by Magnus, twenty-four per cent, of 
the inmates of the institutions for the blind in the differ- 
ent countries of Europe owe their loss of sight to this 
one disease — a showing wholly inexcusable, as it is 
largelv the result of unpardonable neglect and ignorance 
on the part of those having the care of the new-born. 

One of the not very unusual consequences of gonor- 
rheal conjunctivitis is anterior staphyloma. (See Plate 
VI, Fig. I.) In the less severe cases, or in those in 
which treatment has been begun promptly, necrosis of 
the cornea, if it occurs, is more apt to be circumscribed. 
Under such circumstances an opacity of the cornea is 
left, and to this a knuckle of the iris is frequently adher- 
ent (anterior synechia). (See Fig. 100.) The degree 
of impairment of vision in such cases will depend upon 
the density and the location of the opacity, whether it 
is central or peripheral, and upon the situation of the 
displaced pupil. 

Treatment. — As a preliminary step to the employment 
of remedial measures, if there be any doubt as to the 
diagnosis, the discharge from the eye should be sub- 
jected to microscopic examination, in order that the 



1 62 



PREVALENT DISEASES OF THE EYE. 



presence or absence of the gonococcus may be deter- 
mined. Its presence in the discharge definitely estab- 
lishes the diagnosis (Fig. 67). Failure to find it at one 
examination, however, is not conclusive. Therefore, if 
the general symptoms point to gonorrheal infection re- 
peated microscopic examinations should be made, and, 
meantime, it is safest to treat the case as though 
its specific character had been established. The fact 
that the disease is acquired at times in an entirely 





Fig. 67. — a, Gonococci free and in the cells (Bumm); b, gonococci in the 
conjunctival tissues (Bumm). 



innocent manner, and by persons who have not them- 
selves had gonorrhea of the genito-urinary tract, should 
not be lost sight of. 

To secure the best results, it is essential that the 
treatment should be begun promptly, and that it should 
be carried out intelligently and assiduously; for there 
is no other disease of the eyes, it may be remarked, 
which demands such unremitting attention. 

Until the disease is well under control, that is to say, 



DISEASES OF THE CONJUNCTIVA. 163 

until there has been a decided abatement of the con- 
junctival inflammation, of the edema of the lids, and 
of the discharge, the eye should be bathed as often as 
every hour or, if practicable, every half hour, day and 
night, with a saturated solution (gr. xviij to gj) of 
bcracic acid, pledgets of absorbent cotton, wet with 
this solution, being used to douche the eye, and to re- 
move the discharge from the lids and from the con- 
junctival sac. While this should be done as thor- 
oughly as practicable, it should be done with a gentle 
hand, and the greatest care should be exercised not 
to abrade the corneal epithelium, since this accident 
materially increases the danger of corneal ulceration. 

In addition to this careful cleansing of the eye, in 
the adult form of the disease ice-cloths, if found to 
afford relief, as is usually the case, should be applied 
constantly to the lids. The only contraindication to 
their use is the existence of a thin, watery discharge, 
accompanied by a membranous exudation upon the 
surface of the conjunctiva. In such cases the likeli- 
hood of corneal necrosis — always great, as has been 
pointed out — may be increased by the depressing 
effect of cold; therefore, until the character of the 
discharge changes, until it becomes purulent, it may 
be desirable even to employ hot fomentations instead 
of the cold compresses. 

The "ice-cloths," consisting of pads of absorbent 
gauze made cold by lying upon a block of ice, which 
is kept close at hand, must be changed frequently 
to afford the best results. An intelligent and not too 
awkward patient may be trusted to carry out this feature 
of the treatment himself. In ophthalmia neonatorum 
the application of cold is not, in my judgment, called 
for. In the first place, it is impracticable to apply it 



164 PREVALENT DISEASES OF THE EYE. 

effectively, and, in the next place, as abundant experi- 
ence proves, the withholding of it does not influence 
unfavorably the progress of the disease. 

The other measure of importance in the treatment 
of purulent ophthalmia consists in the careful appli- 
cation of a sufficiently strong solution of argyrol or 
protargol. Formerly, in common with most ophthal- 
mic surgeons, I employed in this disease silver nitrate, 
usually in two per cent, solution; but my experience 
with these newer agents has been so eminently satis- 
factory that I now feel warranted in using one or the 
other, as a matter of routine, instead of the silver nitrate. 
The advantages of argyrol and protargol are that they 
are more penetrating in their action, that they seem to 
control the inflammation more effectually, and that 
even the strongest solutions are far less irritating than 
are the comparatively weak solutions of the older salt. 
To be effective, however, it is essential that they should 
be used in strong solution. A forty per cent, solution 
(forty parts to sixty parts of water) is about a saturated 
solution of protargol, and this is the strength in which 
I am in the habit of using it, one application being 
made to the eve daily, in addition to which a weaker 
solution (ten to twenty per cent.) is applied twice each 
day. Argyrol, being more soluble, can be used in 
stronger (fifty per cent.) solution, and, being less irri- 
tating, can be applied more freelv — as often as three 
times a day. 

When practicable, the application should be made 
to the everted lids, by means of a cotton mop; but when, 
as usually happens, it is impracticable to evert the lids 
the solution should be applied, as thoroughly as possible, 
to the palpebral and bulbar conjunctiva with a mop or 
an eye-dropper, as may be found more effective. An- 



DISEASES OF THE CONJUNCTIVA. 165 

other useful measure is the instillation, once or twice 
a day, of a sterile solution of atropin — a four-grain-to- 
the-ounce solution in the case of adults, a one-grain 
solution in infants. This, besides affording the patient 
a measure of relief, favorably influences any corneal 
complication which may be present. 

In ophthalmia neonatorum both eyes, as has been 
stated, are usually infected at birth, and when this is 
not the case subsequent infection of the second eye 
is almost sure to occur, in spite of any efforts which 
may be made to prevent it. In the adult form of the 
disease, on the other hand, while the danger of involve- 
ment of the fellow-eye is always great, it is, as a rule, 
possible with proper precautions to avoid this. There 
are several ways in which infection of the sound eye 
may occur. The greatest danger is that the patient 
may transfer the discharge from one eye to the other 
with his fingers. There is also the possibility that in 
bathing the affected eye some of the pus may find its 
way into the other eye; and, again, if, through lack 
of attention, the discharge is allowed to accumulate, 
it may flow across the bridge of the nose, and thus 
reach the sound eye. 

To lessen the risk of the second eye becoming in- 
fected, it is the practice with many surgeons to seal up 
this eye hermetically by means of what is known as 
Buller's shield (Fig. 68). This consists of a watch-glass 
secured between two suitably shaped pieces of rubber 
adhesive plaster, in each of which a circular opening, 
smaller than the watch-glass, has been cut. This is 
fastened over the eye in such manner as to permit free 
movements of the lids, being applied with exactness to 
the brow, side of the nose, and lower margin of the orbit. 
To render it more secure, reinforcing strips of plaster 



l66 PREVALENT DISEASES OF THE EYE. 

should be used, and, as infection is most apt to occur 
at the nasal edge of the shield, a coating of collodion 
should be applied here. The employment of the watch- 
glass (the suggestion of Dr. Buller) enables the patient 
to use the eye, and the surgeon to inspect it, and to 
watch for signs of commencing inflammation. 

An objection to the use of the shield is that one 
seldom knows, when a case of monocular purulent 
conjunctivitis comes under observation, whether in- 
fection of the other eye may not have occurred already. 




Fig. 68. — Buller's shield (Ffansell and Sweet). 

If this has happened, it is of the utmost importance, 
in order that no time should be lost in the employment 
of energetic therapeutic measures,* that we should be 

* The advice given in most text-books upon diseases of the eye, 
that in gonorrheal conjunctivitis the use of silver nitrate should not 
be begun too early, should not be commenced, in fact, until the dis- 
charge has assumed a distinctly purulent character, is, in my opinion, 
wholly bad. The sooner the silver salt (whether the nitrate or pro- 
targol or argyrol) is begun, the greater is the probability that the 
disease will be kept under control, and that the eye will be saved. 
That I have never lost the second eye, when it became involved 
while the case was under my observation, I attribute to the fact that 
the nature of the affection was recognized at the very outset, and that 
energetic treatment (the use of a silver salt) was begun without a 
moment's delay. 



DISEASES OF THE CONJUNCTIVA. l6j 

able to detect the very first signs of beginning conjunc- 
tivitis, and, unquestionably, this cannot be done as well 
when the shield is in position. Moreover, the confin- 
ing effect of the shield (although, with the view of ob- 
viating this, its temporal edge is usually left free for 
ventilation) tends of itself to excite a conjunctivitis 
of catarrhal type, which must necessarily befog the 
situation. 

In addition to warning the patient as to the risk of 
infecting his sound eye, it is the duty of the physician 
to impress upon those, nurses or others, who may have 
charge of a case of gonorrheal conjunctivitis, how 
important it is that they should exercise the greatest 
care to guard against infection not only of the patient's 
other eye but of their own eyes and of the eyes of others 
about them. He should instruct them not to touch 
the patient's sound eye with infected fingers; to be 
careful, in bathing and making applications to the 
affected eye, not to permit any discharge or any possi- 
bly infected fluid to find its way into the other eye; 
to allow no infected dressings or solutions to stand about 
where harm might come from them, and after each 
handling of the patient's eye to wash their hands, im- 
mediately and thoroughly, with soap and water. 

In adults, internal remedies are at times indicated — 
morphin to relieve severe pain, trional to control less 
severe pain and to induce sleep, quinin in liberal doses 
when necrosis of the cornea threatens, or in combi- 
nation with iron when the vitality of the patient is 
reduced. 

Much benefit has resulted from the prophylactic 
measures proposed by Crede for the prevention of 
ophthalmia neonatorum, and they should be resorted 
to in every case in which the mother is known to have 



l68 PREVALENT DISEASES OF THE EYE. 

a specific vaginitis, or in which there is a suspicion that 
such is the case. These measures consist in the syring- 
ing of the vagina for some days previous to and during 
labor with a three per cent, solution of carbolic acid, 
and in a single careful application of a two per cent, 
solution of silver nitrate to the infant's eyes directly 
after birth or, at least, as soon as they have been thor- 
oughly cleansed. Protargol has recently been substi- 
tuted for the silver nitrate with excellent results. It 
should be used in ten per cent, solution, in which 
strength it is far less irritating than the two per cent, 
silver nitrate solution recommended by Crede. 

Croupous or Membranous Conjunctivitis. — It 
is with some hesitation that this variety of conjunctival 
inflammation is described as a distinct disease, since 
there are excellent reasons for regarding it rather as 
a type of inflammation prone to occur, under favoring 
conditions, in several different kinds of conjunctivitis. 
Reference has been made to the fact that in certain 
unfavorable cases of purulent conjunctivitis, attended 
by a thin, watery discharge, a membranous exudation 
tends to form upon the palpebral, and at times upon 
the bulbar, conjunctiva; and it may be added that a 
similar disposition occasionally manifests itself in 
catarrhal conjunctivitis. A typical form of mem- 
branous conjunctivitis is that which is induced by the 
application of the jequirity bean in the treatment of 
trachoma. Rarely, a chronic form of croupous con- 
junctivitis is met with, in which the membrane forms 
and re-forms for weeks and even months. 

In true diphtheria of the conjunctiva the membrane 
frequently forms upon the bulbar as well as upon the 
palpebral conjunctiva; but in the milder affection 
under consideration the exudate, which does not invade 



DISEASES OF THE CONJUNCTIVA. 169 

the subconjunctival tissue as in true diphtheria, and 
can, as a rule, be easily detached, is usually confined 
to the conjunctiva of the lids. In croupous conjunc- 
tivitis the danger of corneal implication is slight; but 
there is commonly more pronounced ciliary irritation 
and more decided edema of the lids than is found in 
catarrhal conjunctivitis. The discharge is scant and 
watery. Usually after a few days the membrane — 
which consists of a meshwork of coagulated fibrin, pus 
corpuscles, and epithelial cells — ceases to be formed, 
and the case assumes the features of a severe catarrhal, 
or, perhaps, of a purulent, conjunctivitis. 

The condition of the system seems to have much 
to do in determining this type of conjunctival inflam- 
mation. Unhealthy, ill-nourished children — the sub- 
jects of inherited syphilis, for example — are especially 
prone to it. It may be induced also by the injudicious 
employment of too severe remedies in catarrhal and 
in purulent conjunctivitis, as, for example, unduly 
strong solutions of silver nitrate. 

Treatment. — This should be constitutional as well 
as local. Iron and quinin internally, and mild appli- 
cations to the eyes, are indicated. Boracic acid (gr. 
x-xv to gj) is useful, as is also a 1 : 8000 solution of 
corrosive sublimate. Atropin (gr. j to Sj) may be 
employed when there is marked ciliary irritation. 
After the formation of the membrane has ceased, and 
the discharge, previously watery, has become muco- 
purulent, astringents (zinc, sulphat., gr. ss; acid, 
boracic, gr. x; aq. destil., §j, or protargol in two to 
four per cent, solution) are called for, but should be 
used with caution. 

Diphtheritic Conjunctivitis. — True diphtheria of 
the conjunctiva, characterized by the presence of 



170 



PREVALENT DISEASES OF THE EYE. 



the Klebs-Loffler bacillus — to which condition the 
term "diphtheritic conjunctivitis" should be restricted 
— is not among the commoner diseases of the eye; 
still, as it is an affection which mav be encountered 
at anv time by the general practitioner, a brief account 
of it seems to be called for. 

Like faucial diphtheria, diphtheritic conjunctivitis, 
one of the most dangerous diseases to which the eye 
is subject, occurs more frequentlv in children than in 
adults. The onset of the disease is sudden, and its 





Fig. 69. — Diphtheritic conjunctivitis in a child (Haab). 

development rapid. Severe pain is experienced, and 
the lids are not only red and greatly swollen, but, 
owing to the character of the infiltration, are tense and 
brawny (Fig. 69). The discharge at first is thin, 
ichorous, and scanty, but at a later stage frequently 
becomes purulent. The membrane, which usually 
forms upon the ocular, as well as upon the palpebral, 
conjunctiva, is thick and coherent, grayish in color, 
and extends so deeply into the subconjunctival tissue 
that it is not possible to detach it (Fig. 70). Destruction 
of the cornea, in consequence of the rapid and extensive 



DISEASES OF THE CONJUNCTIVA. 171 

infiltration of the bulbar conjunctiva interfering with 
its nourishment, is the result which is most to be 
dreaded. Deep sloughs, involving not only the con- 
junctiva but the subconjunctival cellular tissue, may 
occur, and the contraction resulting from this destruction 
of tissue is apt to produce entropion with its attendant 
ill consequences. The constitutional symptoms which 
are present in faucial diphtheria — fever, general depres- 
sion, etc. — manifest themselves. Usually both eyes are 
involved, though this is not always the case. 




Fig. 70. — Diphtheritic conjunctivitis in a child (Haab). 

The infection of the eye may be direct and primary, 
or it may be secondary to diphtheria of the throat and 
nose, occurring as a result of accidental inoculation or 
of extension through the lacrimal passages. Occa- 
sionally the disease manifests itself after operative 
procedures upon the eye. Atypical examples of diph- 
theritic conjunctivitis have been observed, in which 
the brawny infiltration of the lids and the conjunctival 
false membrane are absent, and yet rapid destruction 
of the cornea occurs, and the Klebs-L6ffler bacillus 
is found to be present (Fig. 71). 



172 PREVALENT DISEASES OF THE EYE. 

Treatment. — The most important therapeutic meas- 
ure, as in the faucial type of the disease, is the injection 
of the diphtheria antitoxin. The results of this plan 
of treatment have been most gratifying, and, as Jackson 
expresses it, "its importance overshadows that of all 
local remedies." Quinin, iron, stimulants, and a 
nutritious diet are also indicated. The local treatment 
consists in the application of warm fomentations, the 
lotion of opium and boracic acid (ext. opii, gr. x; acid. 



*/£■* 



\ 









A~ 






Fig. 71. — Bacillus diphtherial, from a culture upon blood-serum; X 1000 
(Frankel and Pfeiffer). 

boracic, gr. xl; aq. destil., §iv) being one of the best, 
and, for direct application to the eye, mild antiseptic 
rather than caustic or astringent solutions. Among 
these boracic acid, in saturated solution, and bichlorid 
of mercury (i : 8000) are, perhaps, the most useful. 
A two per cent, solution of potassium permanganate 
is also recommended. 

When the disease is limited to one eye, the same 
precautions should be taken as in purulent conjunc- 



DISEASES OF THE CONJUNCTIVA. 1 73 

tivitis to prevent inoculation of the fellow-eve. Those 
in attendance should also be warned of the danger of 
inoculating their own ocular or faucial mucous mem- 
brane. During the declining stage of the disease, when 
the membrane has been thrown off, and the discharge 
has become purulent, protargol in ten per cent., or 
silver nitrate in one per cent., solution may be employed 
with advantage. 

Follicular Conjunctivitis. — The seat of this affec- 
tion is chiefly in the palpebral conjunctiva and in the 
retrotarsal folds, though more or less pronounced hyper- 
emia of the bulbar conjunctiva is often observed. Its 
characteristic feature is the presence of enlarged folli- 
cles — hypertrophied lymphoid tissue — in the superior 
and inferior retrotarsal folds. In well-marked cases 
it bears a close resemblance to the follicular type 
of trachomatous conjunctivitis; but the hypertrophied 
papillae observed in this disease are not present, the 
enlarged follicles are more definitely limited to the retro- 
tarsal folds, and it does not lead to pannus or deform- 
ity of the lids. It is at times, however, an obstinate 
affection, and not infrequently shows but little disposi- 
tion to respond to treatment. It is an interesting fact 
that the negro race, which is almost immune from tra- 
chomatous conjunctivitis, is especially prone to this 
variety of conjunctival inflammation. It is probably of 
microbic origin, but this has not been demonstrated. It 
is attended by a slight, mucous discharge, by a feeling 
as though dust were in the eyes, and sometimes by 
itching. 

Treatment. — A collyrium of corrosive sublimate 
(1 : 12,000 to I : 8000) with sodium chlorid (one per 
cent.) is the remedy which I have found most useful. 
Zinc sulphate and boracic acid, as recommended in 



174 PREVALENT DISEASES OF THE EYE. 

catarrhal conjunctivitis, and protargol (in two to five per 
cent, solution) I have also employed with good effect. 

Trachomatous or Granular Conjunctivitis 
(Granular Lids). — The distinctive characteristics of 
this variety of conjunctivitis, which expends its force 
chiefly upon that portion of the conjunctiva which 
lines the lids and constitutes the retrotarsal folds, 
are its chronicity, the marked structural changes 
which it causes not only in the conjunctiva but in the 
subconjunctival tissue as well, and the secondary 
changes, known as pannus, which it induces in the 
cornea. 

Its pathology is as yet but imperfectly understood; 
but it is, without doubt, a contagious disease, the pro- 
duct of a specific organism. A small diplococcus, 
first described by Sattler, is held by some to be the 
organism which produces it, but this has not been 
conclusively shown. 

Although one of the most intractable diseases of the 
eye with which we have to deal, and in its ultimate 
consequences as disastrous to sight as any, trachoma- 
tous conjunctivitis does not, like purulent conjunc- 
tivitis, threaten the eye with immediate destruction. 
The inflammation does not approach in intensity that 
which characterizes the latter disease; nevertheless, 
during the acute stage which supervenes upon inocu- 
lation, there is usually marked conjunctival injection, 
with considerable swelling of the lids, and pronounced 
photophobia, lacrimation, and blepharospasm. The 
discharge, which is not abundant, is mucoid or muco- 
purulent in character. The first evidences of corneal 
implication, a slight roughening of the external epi- 
thelial layer, may become manifest within a few weeks 
of the onset of the attack. 



DISEASES OF THE CONJUNCTIVA. 



*75 



With the subsidence of the more acute symptoms the 
chronic stage of the disease begins, and this, if left to 
itself, may last a lifetime, rendering existence miserable, 
and reducing the individual to a state of helplessness 
and dependence; for not only is the sight greatly im- 
paired, as a result of the corneal changes, but the eyes 
(for both eyes are commonly involved, though exceptions 
to this rule are encountered) are persistently irritable 







Fig. 72. — Section of a trachoma follicle from the retrotarsal fold. 
Magnified 24 X 1 (Fuchs). The trachomatous granulation, T, pushes 
up the conjunctiva in the form of an elevation, and is inclosed by a layer 
of thickened connective tissue, the capsule, k. The conjunctiva is in- 
filtrated with cells, both in its upper layers, a, and along the vessels, g; 
the epithelium, e, shows, above the place marked a, bright spots which 
correspond to the goblet cells; at d, it lines one of Henle's glands. 



and photophobic, and lacrimation and blepharospasm 
are generally present. 

It is usual to describe two varieties of the disease — 
a papillary and a follicular. In the former the dis- 
tinctive feature is hypertrophy of the papillae of the 
tarsal conjunctiva (Plate III, Fig. 3); in the latter, the 
presence in the conjunctiva of the tarsus and in the retro- 
tarsal folds of the so-called "trachoma granules" or 
"trachoma follicles. " More often the affection is of a 
mixed type, both of these features being present. The 



176 



PREVALENT DISEASES OF THE EYE. 



trachoma follicles, which are made conspicuous by 
everting, the lids and causing the retrotarsal folds to 
protrude, are translucent bodies, having a resemblance 
to boiled sago grains or frog's spawn. Recent investi- 
gation seems to show that they are, in fact, hypertro- 
phied lymphoid and connective-tissue cells, enclosed in 
a fibrous envelope (Fig. 72). The hypertrophy of the 
papillae of the tarsal conjunctiva, which is observable 




Fig- 73- — Cross-section through the trachomatous conjunctiva of 
the upper lid. Magnified 24 X i (Fuchs). Both small papillae, P, P, 
and large ones, P v P 1? are found. The former stand side by side like 
the pickets of a palisade; the depressions, t, t, lying between them and 
coated with epithelium, look like the tubules of glands. The large pa- 
pillae contain trachoma granules, T, T 1} which are not sharply limited 
and do not possess a capsule. The epithelium of the conjunctiva is in many 
places, e, e, thickened. The mucous coat is in a condition of cellular in- 
filtration, which is especially marked in the vicinity of the blood-vessels, 
g> g- 



chiefly upon the upper lid (Fig. 73), and the develop- 
ment of the trachoma follicles are accompanied by 
pronounced hyperplasia of the submucous connective 
tissue. 

Ultimately there supervenes a stage of atrophy (Fig. 
74), which in the worst cases results in the condition 
known as xerophthalmia, in which the conjunctiva — 
itself so atrophied that the retrotarsal folds are obliter- 



DISEASES OF THE CONJUNCTIVA. 1JJ 

ated, and free movements of the lids and eyeball cur- 
tailed — loses the character of a mucous membrane, and 
becomes dry and cuticular, while the cornea becomes so 
opaque that vision is reduced to little better than light 
perception. A more common consequence of this atro- 
phic process and of the contraction which accompanies 
it, is the development of entropion (Fig. 75), that very 
annoying condition in which the lid-margins are in- 
verted, and the eyelashes come in contact with, and 



Fig. 74. — Cicatricial stage of trachoma with pannus (Hansell and Sweet). 

constantly irritate, the bulbar conjunctiva and the 
cornea. (See Chapter upon Diseases of the Eyelids 
and Orbit.) 

The secondary changes which occur in the cornea, 
it seems probable, are largely due to the mechanical 
violence to which it is subjected through constant fric- 
tion with the roughened inner surface of the lids. At 
first the cornea shows a mere loss of luster, a slight 
roughening of its surface; but soon it becomes more 
decidedly opaque; numerous blood-vessels develop 



1 7 8 



PREVALENT DISEASES OF THE EYE, 



upon it; its surface becomes uneven; and from time 
to time sluggish ulcers make their appearance — these 





Fig. 75. — Schematic section through the lids and eyeball (A, in recent, 
B, in old trachoma) (Fuchs). A shows the way in which the two forms 
of hypertrophy of the conjunctiva are distributed among the separate divi- 
sions of the latter; B, the stage of sequelae of trachoma, s, s lf eyebrows; 
0, o v furrow between the brow and the lid (sulcus orbito-palpebralis) ; d, 
d v covering fold; c, cilia in their proper position; c v cilia turned toward 
the cornea; r, free border of the lid, with the borders of the upper and 
lower lids running parallel and the posterior margins of the lids acute; 
r v free border of the lid, looking backward, and with its posterior margin 
rounded; /, tarsus thickened by infiltration and covered with the velvety 
conjunctiva tarsi; t v tarsus thinned (atrophic), bent at an angle near its 
free extremity, and covered with smooth epithelium; /, fornix with nu- 
merous trachoma granulations, T, in the folds of the conjunctiva; f Xi 
fornix smooth, without folds (symblepharon posterius); p, thick pannus 
covering the upper half of the cornea; p v a shrunken pannus, extending 
over the whole cornea. 



changes being more marked upon the upper half of the 
cornea, because here the lid friction is greatest. 

Although, as has been stated, unquestionably a 
contagious disease, the contagium which gives rise 



DISEASES OF THE CONJUNCTIVA. I79 

to trachomatous conjunctivitis, fortunately, is non- 
volatile, and so the disease can be communicated only 
by actual transference of the discharge from one eye 
to another. This commonly occurs through the 
medium of towels, handkerchiefs and the like, and 
it is for this reason that the affection so often flourishes 
in orphan asylums, reformatories, workhouses, etc. 

Filth, unhygienic surroundings, uncleanly habits, 
and ill-nourishing food unquestionably favor the de- 
velopment and spread of this loathsome malady; but 
the view, not infrequently expressed, that trachoma 
may actually originate from such conditions, may de- 
velop without a pre-existent case to supply the con- 
tagium, is, it seems to me, absurd; as absurd, indeed, 
as to suppose that smallpox or cholera might originate 
in similar fashion. It is a fact of interest that certain 
races, the Jews and the Irish, for example, exhibit an 
especial predisposition to the disease, while, on the 
other hand, the negro is practically immune from it. 

In the early stages of trachomatous conjunctivitis 
it is not always possible to reach a definite diagnosis; 
for there are less severe forms of conjunctival inflamma- 
tion, more especially follicular conjunctivitis, in which 
hypertrophy of the palpebral lymphoid tissue and 
frog-spawn-like follicles are observed. However, the 
behavior of the case under treatment, and especially the 
occurrence of pannitic corneal changes, soon establish 
the true nature of the affection. In the chronic stage 
of the disease the distinctive features are pannus (Figs. 
74 and 76), more or less evident entropion, and the 
presence of irregular, linear scars upon the conjunctival 
surface of the upper lid. 

Treatment. — The treatment of this affection yields 
far from satisfactory results, and even in the most 



i8o 



PREVALENT DISEASES OF THE EYE. 



favorable cases must be long-continued to be effective. 
Moreover, relapses are of common occurrence, and, for 
this reason, it is well to give a guarded prognosis as to 
the future. Silver nitrate (in two to four per cent, 
solution) in the earlier stages, and copper sulphate (in 
the form of a crystal, applied to the everted lids) at 
a later stage, are the remedies which formerly were 
chiefly relied upon, and which are still extensively 
used. However, recent experience has led me to the 



E I 




Fig. 76. — Cross-section through the margin of a cornea affected with 
pannus. Magnified 125 X 1 (Fuchs). Beneath the epithelium, E, E, 
is the limbus, L, greatly thickened by cellular infiltration; from it the pan- 
nus, P, in which are perceived the cross-sections of several vessels, extends 
between the epithelium and Bowman's membrane, B, over the cornea, C. 
S, sclera. 



conclusion that in trachomatous, as in purulent con- 
junctivitis, protargol may be employed with advantage 
as a substitute for the silver nitrate. I am also in- 
clined to believe that it accomplishes as much in the 
chronic stage of the disease as any other remedy, and 
so I find myself using it instead of the copper sulphate, 
the application of which is so much more painful. 

My practice, in the acute as well as in the chronic 
stage of the disease, is to apply to the everted lids, 
every other day, a forty per cent, solution of protargol, 



DISEASES OF THE CONJUNCTIVA. l8l 

and to prescribe a weaker solution (ten to twenty per 
cent.) for application by the patient twice daily. If 
he can be taught to evert the lids, and make the appli- 
cation directly to their inner surfaces, this is distinctly 
advantageous; but, if this is not practicable, the solu- 
tion is applied by means of an eye-dropper. When 
corneal ulcers, attended, as they usually are, by photo- 
phobia, are present, the protargol treatment is sup- 
plemented by the instillation, three times a day, of a 
two- to four-grain solution of atropin or a one- to two- 
grain solution of holocain. The other remedial meas- 
ure chiefly relied upon is the use of the roller forceps 
of Knapp (Fig. yj). This treatment has been found 
especially useful in the follicular type of the disease, 



Fig. 77. — Knapp's roller-forceps. 

the forceps being employed, from time to time, to 
squeeze out any "trachoma follicles" which may be 
discovered in the tarsal conjunctiva or in the retrotarsal 
folds. To lessen the considerable pain which attends 
this procedure, the eye should be brought well under 
the influence of cocain. The lid is then everted, and 
the forceps are made to grasp the everted cartilage or 
the retrotarsal folds of the conjunctiva, and the follicles 
are expressed by gentle traction, combined with not- 
too-firm compression of the blades (Fig. 78). 

Should the condition of the eyes not improve under 
the use of protargol, silver nitrate in two per cent, 
solution, or the crystal of copper sulphate, to be applied 
not oftener than every other day, should be tried instead, 
or a crystal of alum, which the patient may apply to 



182 



PREVALENT DISEASES OF THE EYE. 



the everted lids two or three times a day, and which 
sometimes is very beneficial, may be prescribed. A 
five per cent, ointment of copper citrate, to be applied 
two or three times a day, is one of the newer remedies 
claimed to be useful in this condition. When entropion 




Fig. 78.— Expression of trachoma follicles with Knapp's roller forceps 
(Hansell and Sweet). 



is present, removal of the inverted lashes affords tem- 
porary relief (Fig. 79). To secure permanent relief the 
lid-fault must be corrected by operative procedure (see 
Chapter III). 

In cases which exhibit marked pannus, with a plenti- 



DISEASES OF THE CONJUNCTIVA. 183 

ful supply of blood-vessels upon the cornea, much may 
be accomplished by the jequirity treatment; but the 
risk of serious corneal complications attending the use 
of this remedy is so considerable, that one hardly feels 
warranted in recommending its employment by the 
general practitioner. 

Vernal Conjunctivitis or Spring Catarrh.— This 
very obstinate form of conjunctival inflammation is 
met with chiefly in children. It usually attacks both 
eyes, and is probably mildly contagious. It derives 
its name from the fact that the disease remains com- 
paratively dormant during the winter, and becomes 
more active and troublesome with the oncoming of 
warm weather. Though probably dependent upon 




Fig. 79. — Epilation-forceps. 

a specific germ, the efforts to discover this have so far 
proved fruitless. 

Two types of the disease are met with. In one, the 
bulbar conjunctiva is the seat of the characteristic 
changes; in the other, they are found in the conjunctiva 
of the tarsus. Well-marked examples of the two types 
are rarely met with in the same individual; at least, 
this has been my experience. In the bulbar variety 
(Fig. 80) there is observed a slightly elevated, nodular, 
gelatinous growth, of yellowish-brown color, upon the 
conjunctiva, close to the corneal border. In some in- 
stances this growth exhibits a tendency to encircle the 
cornea, as a rather narrow band; in others it tends to 
spread upon the conjunctiva, especially in the direction 
of the inner and outer canthi, and, to a less extent, 



1 84 



PREVALENT DISEASES OF THE EYE. 



upon the cornea. In rare cases the whole cornea is 
overrun, and the sight in consequence is greatly im- 
paired. The nodular masses, which are stable and 
show no disposition to ulcerate, are composed of 
connective tissue and greatly thickened epithelium, 
the latter showing a tendency to extend into the under- 
lying tissue in the form of solid epithelial plugs (Fuchs). 
In the palpebral variety the papillae of the tarsal 
conjunctiva, and to a less extent those of the re- 





Fig. 80. — Vernal con- 
junctivitis (bulbar type) 
(Haab). 



Fig. 81. — Vernal conjunctivitis, showing typ- 
ical palpebral as well as bulbar changes (Dr. 
Wm. Zentmayer's case) (Hansell and Sweet). 



trotarsal folds, undergo a peculiar hypertrophy, and 
at the same time become flattened (probably from the 
constant pressure to which they are subjected), so 
that the inner surface of the lid (it is the upper lid 
which commonly exhibits these changes) presents a 
strikingly tessellated appearance. The hypertrophied 
papillae (admirably shown in the accompanying illus- 
tration, Fig. 81) are as firm almost as cartilage, and 
their edges, which overhang in mushroom-like fashion* 



DISEASES OF THE CONJUNCTIVA. 185 

can be slightly elevated. According to Fuchs, they are 
composed of areolar connective tissue, with connective- 
tissue cells which have undergone a peculiar hyaline 
degeneration, and are covered by thickened epithelium, 
which gives to the conjunctival surface of the lid the 
bluish-white, skimmed-milk appearance that is a fea- 
ture of the disease. 

The most prominent symptom of vernal catarrh is per- 
sistent itching. Pain is not complained of, but rather 
a sensation of sand being in the eyes. The discharge 
is slight. Not infrequently the disease lasts for years, 
and rarely is it of brief duration. It is not uncommon 
to meet with more than one case in members of the 
same family. For instance, the author has encountered 
marked examples of the palpebral variety in a father 
and his two sons, and also in sisters who were twins. 

Treatment. — As a rule, the disease, especially when 
it is well marked, responds to treatment very unsatis- 
factorily. The remedy which has yielded me the best 
results is bichlorid of mercury. This is prescribed as 
a collyrium, in the strength of 1 : 8000, with the addition 
of one per cent, sodium chlorid, and is dropped into 
the eyes three times a day. To be effective the remedy 
must be long continued, although in the milder cases 
improvement may manifest itself within two or three 
weeks; in the more severe cases it is a matter of months 
rather than weeks. Other remedies which may be 
tried are zinc sulphate and boracic acid, as recom- 
mended in catarrhal conjunctivitis; yellow oxid of mer- 
cury ointment (hydrarg. ox. flav., gr. j; vaselin, 5j)> 
to be applied to the eye once a day; dilute acetic acid 
(1 part of the dilute acid to 250 parts of water), to be 
dropped into the eye three times a day, as recommended 
by Van Millingen, and salicylic acid ointment, two 



l86 PREVALENT DISEASES OF THE EYE. 

to fifteen per cent., as suggested by Randolph. The 
internal administration of syrup of iodid of iron has 
seemed to me, at times, to be of benefit, and in the 
palpebral type of the disease I have thought that good 
resulted from the use of the roller forceps, employed 
as in trachoma. 

Phlyctenular or Scrofulous Conjunctivitis. — 
The essential feature of this form of conjunctivitis, 
which is known also as conjunctivitis lymphatica and 
as eczema conjunctiva, is its dependence upon a con- 
stitutional cause. Though not infrequently met with 
in adults, it is a disease to which children are especially 
disposed. It happens as often that both eyes are 
affected as that one only is involved. 

In the typical form of the disease the conjunctival 
injection is not uniform, but is more marked in, or, 
perhaps, is confined to, the neighborhood of the phlyc- 
tenular (Plate IV, Fig. i). These are yellowish-red 
elevations, differing in size from that of a mustard-seed 
to a small split pea, and composed chiefly of lymphoid 
cells, which, in varying numbers, — usually two or three, 
— develop upon the ocular conjunctiva, more especially 
in the neighborhood of the corneal border, and are con- 
verted quickly into superficial ulcers through loss of 
their epithelial covering. Pain is not a symptom of the 
disease, but photophobia and lacrimation are frequently 
present. The discharge is mucoid, and is less abundant 
than in catarrhal conjunctivitis. The affection is not 
contagious. 

As often as not the phlyctenular make their appear- 
ance upon the cornea as well as upon the conjunctiva, 
and then the affection is known as phlyctenular kerato- 
conjunctivitis. Under such circumstances the photo- 
phobia is apt to be more pronounced — in some instances 



PLATE IV, 



Fig. i. — Phlyctenular Conjunctivitis. 



IS 



ik < o U t a. 
I 

Fig. 2. — Pterygium. 



DISEASES OF THE CONJUNCTIVA. 187 

intense — and to be attended by blepharospasm and 
profuse lacrimation. It is through involvement of the 
cornea that the disease, at times, permanently and 
seriously damages the eye. In consequence, usually, 
of neglect or of injudicious treatment, the corneal 
ulcers left by the breaking-down of the phlyctenular 
extend laterally and in depth until, perhaps, a perfora- 
tion into the anterior chamber occurs or, at all events, 
until the cornea is seriously damaged. A leucoma, or 
dense opacity of the cornea, results, which, if central 
or nearly central, greatly impairs the sight. More than 
this, if the ulcer perforates into the anterior chamber, 
a permanent adhesion of the iris to the cornea at the 
point of perforation is almost sure to occur, and this 
is usually attended by distortion and displacement of 
the pupil (see Fig. ioo). 

When phlyctenular conjunctivitis presents the typical 
appearance which has been described, it is not difficult 
of recognition. Occasionally, however, in what may 
be properly termed the catarrhal type of the disease, 
the conjunctival injection is diffuse, and the phlyctenular 
are absent or not distinguishable. Under such cir- 
cumstances the eye presents almost the same appear- 
ance that it does in acute catarrhal conjunctivitis, with 
which it may be confounded, if only the condition of 
the conjunctiva is relied upon as a diagnostic guide. 
However, in true catarrhal conjunctivitis both eyes 
are almost invariably affected, and there are no evi- 
dences of constitutional derangement, whereas, in 
phlyctenular conjunctivitis, as has been pointed out, 
it often happens that only one eye is involved, and 
it is seldom the case that there are not present other 
evidences of constitutional disorder, such as blepharitis 
marginalis, eczema of the face, etc. As the treatment 



l88 PREVALENT DISEASES OF THE EYE. 

called for in catarrhal conjunctivitis (the use of an 
astringent collyrium) is sure to be harmful in phlycten- 
ular conjunctivitis, it is most important that the two 
conditions should not be confounded. It may be 
added, that when the diagnosis is in doubt, especially 
in dealing with children, it is safer to treat the case as 
one of strumous character. 

The name "scrofulous conjunctivitis," or "scrofulous 
ophthalmia," as applied to the affection under con- 
sideration is somewhat misleading; for, though dis- 
tinctly scrofulous individuals show an especial pre- 
disposition to the disease, it is often met with in persons 
who can not properlv be regarded as belonging to this 
category. This is particularly true of the cases which 
are so often encountered in children. Here the ocular 
affection, which is frequently .accompanied by nasal 
catarrh, and by eczema of the lids, the upper lip, and 
the auricle, and not uncommonly by suppurative in- 
flammation of the middle ear, seems to be largely 
dependent upon disorder of the digestive apparatus, 
brought about by improper feeding, by unhygienic 
surroundings, and by lack of pure air and sunlight. 
A furred tongue, "feverish" breath, loss of appetite, 
and constipation of the bowels are other symptoms 
which are often present. 

That in these cases we have to do with a relatively 
mild form of septicemia, due in all probability to the 
entrance into the circulation of bacteria or their toxins 
from the alimentary canal, is a view which I have long 
held, and which I have advanced upon more than one 
occasion. This view seems to be supported not only 
by the clinical features of these cases, which are just 
such as might result from the presence in the blood of 
a relatively benign septic organism ("intestinal intoxi- 



DISEASES OF THE CONJUNCTIVA. 189 

cation" is the way it is expressed nowadays), but also 
by the character of the treatment which proves most 
effective. For of all remedial measures none produces 
so prompt and decided a change for the better — not 
only in the condition of the eye but in the patient's 
general condition — as the administration of a generous, 
old-fashioned, calomel purge, which gives the " primce 
vice" a thorough cleansing. In this connection it may 
be mentioned that careful bacterial investigations, made 
by Weeks and others, show that the Staphylococcus 
aureus is commonly present in the phlyctenular, as it is 
in the eczematous nodules which, as has been stated, 
are so often found in association with strumous con- 
junctivitis. 

Treatment. — There are few diseases of the eye that 
respond to treatment so promptly and satisfactorily 
as does phlyctenular conjunctivitis; but, on the other 
hand, there are few in which injudicious treatment 
does more harm. Astringents — silver nitrate, zinc 
sulphate, etc. — are distinctly contraindicated, and when 
used invariably make matters worse. It goes without 
saying, that the treatment of this affection, in view of 
its systemic origin, should be both constitutional and 
local. 

The local treatment, which is so invariably effectual 
that it need scarcely ever be departed from, may be 
described in a few words. It consists in the applica- 
tion to the eye, three times a day, of a solution of 
atropin and boracic acid, and once a day (preferably 
in the morning, after the atropin has been instilled) 
of an ointment of yellow oxid of mercury and vaselin 
(hydrarg. ox. flav., gr. j; vaselin, 5j). The exact 
quantity of the ointment to be applied is a matter of 
little moment, but a bit the size of a match-head is 



I90 PREVALENT DISEASES OF THE EYE. 

sufficient. It should be carefully inserted between the 
upper or lower lid and the eyeball. This may be done 
conveniently with the broad end of a wooden tooth- 
pick (see Fig. 9), or, more safely, if the treatment is 
to be carried out by untrained hands, with a small 
camel's-hair brush. If blepharitis is present, or eczema 
of the lids, some of the same ointment (or, still better, 
an ointment of twice the strength mentioned, and hav- 
ing "vaselin cerate" rather than vaselin as a base, be- 
cause of its higher melting-point) should be applied to 
the lids at bedtime. 

The strength of the atropin solution prescribed should 
vary with the degree of photophobia, lacrimation, and 
blepharospasm present. When the inflammation is 
confined to the conjunctiva, and there are no phlyc- 
tenular upon the cornea, and when, therefore, as a 
rule, there is but little photophobia, a one-grain- 
to-the-ounce solution of atropin, with ten grains of 
boracic acid, should be ordered. In most cases 
of kerato-conjunctivitis, especially those occurring in 
children, this same strength suffices; but the atro- 
pin should be increased to two, or even to four 
grains, to the ounce, if photophobia and lacrimation 
are pronounced.* Exceptionally, in mild cases, in 
which the conjunctiva only is involved, and in which 
the effect of the atropin upon the sight would cause 
considerable inconvenience, it is permissible to try a 
collyrium simply of boracic acid (ten to twelve grains 
to the ounce) in connection with the yellow oxid of 
mercury ointment; but my experience is that, almost 



* Whenever atropin is prescribed, the effect it will have upon the 
pupil and upon the sight, and the fact that it is very poisonous, should 
always be impressed upon the patient or upon those in whose charge 
he is. 



DISEASES OF THE CONJUNCTIVA. 191 

without exception, the cases do better, and the affection 
yields much more promptly, when atropin is employed. 

For the effectual application of the atropin solution 
an eye-dropper is indispensable, and even with its 
aid, owing to the spasm of the lids, this is not always 
easy of accomplishment. The patient, if a child, 
should be placed in a recumbent position, and will 
probably need to be held firmly while the drops are 
being instilled and the ointment inserted. Neither 
application, it may be observed, causes any pain. 

As to constitutional treatment, this, of course, will 
be influenced largely by the age and the general con- 
dition of the patient. When there are present evidences 
— enlarged lymphatic glands, etc. — of a well-marked 
strumous diathesis, the syrup of the iodid of iron, and 
cod-liver oil combined with the hypophosphites are 
especially useful. In the cases which are less distinctly 
strumous, especially in those which have been described 
as being encountered so often in children, the remedy 
in which experience has led me to place the greatest 
confidence is a combination of the phosphates of iron, 
quinin, and strychnin, given in the form of an elixir or 
a syrup.* The preparations of "beef, wine, and iron," 
which have the advantage of being palatable, a matter 
of no little importance where children are concerned, I 
have also found useful. 

* As has been mentioned before, the elixir of the phosphates of 
iron, quinin, and strychnin made byWyeth & Brother is especially to 
be commended, because it contains a much larger proportion of iron 
and quinin (two grains of the former and one grain of the latter to the 
dram) than do most of the preparations that are called by the same 
name. A syrup prepared by Sharp & Dohme, which contains one 
grain, each, of the phosphates of iron and of quinin and one-sixtieth 
of a grain of phosphate of strychnin to the dram, is another prepa- 
ration which I have used with excellent effect, especially in hospital 
practice. 



I92 PREVALENT DISEASES OF THE EYE. 

As a rule, it is well, especially in those cases, common 
in children, which exhibit besides the ocular inflamma- 
tion other signs of constitutional disorder, such as 
blepharitis, eczema, nasal catarrh, otitis media, etc., to 
administer, at the outset of the treatment, an energetic 
mercurial purgative (calomel, scammony, aa gr. ij; 
rhubarb, gr. vj). The benefit resulting from this 
measure usually is strikingly manifest, and not infre- 
quently the case is well on the road to recovery before 
the tonic treatment, to which it is the prelude, has had 
time to produce its effect. 

The regulation of the diet, it should be added, espe- 
cially in cases occurring in children, who should be 
allowed to have only simple, easily digested, and nourish- 
ing food, is a matter of prime importance. It is impor- 
tant also that patients suffering with phlyctenular con- 
junctivitis or keratoconjunctivitis should be out of 
doors as much as practicable — should have plenty of 
fresh air and sunlight, and should not be shut up in 
darkened and ill-ventilated rooms, as too often happens. 

The exanthematous fevers, measles especially, not 
infrequently give rise to inflammation of the conjunc- 
tiva, and writers often make of these cases a distinct 
variety of conjunctivitis, which they denominate "ex- 
anthematous." There seems to be no good reason for 
doing so, however, as they differ in no essential respect 
from the systemic conjunctivitis that has just been 
described, and, like it, present at times a distinctly 
phlyctenular character, with a tendency to corneal 
implication, and, at other times, a catarrhal type; 
moreover, the treatment which they require is exactly 
the same. 

Toxic Conjunctivitis.— An inflammation of the 
conjunctiva of follicular type, usually accompanied by 



DISEASES OF THE CONJUNCTIVA. I93 

annoying itching, is occasionally excited by the long- 
continued use of collyria containing atropin, hyoscy- 
amin, eserin, and other drugs of similar character. 
Exceptionally, owing to a peculiar susceptibility on 
the part of the individual, a single application of an 
atropin colly rium will induce a marked conjunctivitis, 
which may be accompanied by decided redness and 
edema of the eyelids and even of the whole face. Some- 
times this susceptibility is manifested to all of the com- 
monly employed mydriatics, but usually this is not the 
case. 

Treatment. — This consists in withholding the drug 
to which the susceptibility is shown, and in the use 
of a ten-grain-to-the-ounce solution of boracic acid, 
three or four times daily. This soon restores the eye 
to its normal condition. 

Argyria Conjunctivae. — From the long-continued 
application of silver nitrate to the eye a permanent 
stain of the lower tarsal and retrotarsal conjunctiva, 
and not infrequently of the bulbar conjunctiva as well, 
may result. The "white of the eye" assumes an olive 
tint, while the retrotarsal folds and the inner surface 
of the lids are stained a bluish-gray or slate color. A 
similar discoloration of the conjunctiva is said to occur 
in persons who, owing to the nature of their employ- 
ment, are constantly exposed to the action of silver 
dust. Cases of argyria from protargol have been re- 
ported, and as this agent is more penetrating in its 
action, and can be used more freely than the silver 
nitrate, it is probable that this condition will be met 
with oftener in the future than it has been in the past. 
The stains are indelible. Different agents have been 
employed to remove them, but without success. 

Subconjunctival Hemorrhage. — This condition 
13 



194 



PREVALENT DISEASES OF THE EYE. 



(Fig. 82), which usually manifests itself suddenly, may 
occur spontaneously or may be of traumatic origin. 
Spells of coughing, vomiting, or sneezing may produce it, 
while at other times it occurs, it may be during sleep, 
without assignable cause. The existence of angio- 
sclerosis predisposes to it, as it does to hemorrhages 
in other parts. The blood not infrequently encircles 
the cornea, and spreads over the whole anterior surface 

of the eyeball, giving to it 
a bright-red appearance, 
which leads to the belief 
that something serious has 
happened. It is commonly 
mistaken for "inflamma- 
tion"; but inspection of the 
eye shows that the redness 
is not due to injection of 
blood-vessels. It may give 
rise to a slight soreness of 
the eyeball; but beyond this 
it causes no inconvenience, 
apart from its unsightliness. 
During the process of ab- 
sorption, which may occupy 
two or three weeks, the 
bright-red color of the freshly extravasated blood 
changes to a greenish-yellow. 

Treatment is scarcely called for; but, if it is a matter 
of moment to hasten the restoration of the normal 
appearance of the eye, a compress bandage and the 
internal administration of potassium iodid may be of 
some avail. A lotion of opium and boracic acid is 
useful, when "soreness" of the eyeball is complained of. 
Pinguecula. — An elevation, yellowish in color, and 







V 



Fig. 82. — Subconjunctival hemor 
rhage (Haab). 



DISEASES OF THE CONJUNCTIVA. I95 

varying in size and shape, situated upon the conjunc- 
tiva in the interpalpebral space, usually in close prox- 
imity to the nasal, and less frequently to the temporal, 
margin of the cornea, was given the name Pinguecula 
(from ptnguisy "fat"), because formerly it was sup- 
posed to be due to the deposition of fat in the con- 
junctiva. It is seldom observed in young persons, 
and is oftenest met with in individuals who have 
passed middle life. The fact that it occurs upon 
the most exposed portion of the bulbar conjunctiva 
seems to indicate that it is, in some measure at least, 
due to the irritation caused by wind, dust, etc. Micro- 
scopic investigation has shown that the thickening of 
the conjunctiva is caused mainly by an increase in the 
number and size of its elastic fibers, and that the yellow 
color is due not to the deposition of fat, but to the 
presence of numerous concretions of a yellowish col- 
loid substance (Fuchs). 

Treatment. — Removal of the growth is sometimes 
indicated on account of its unsightliness, and in other 
instances because, when unusually prominent, it may 
cause mechanical irritation. It may be excised with 
slender curved scissors, care being taken to sacrifice 
as little as possible of the neighboring conjunctiva. 
The edges of the conjunctival wound should be slightly 
undermined, and brought together by one or two fine, 
black silk sutures, which should be removed after two 
or three days. 

Pterygium is a circumscribed hypertrophy of the 
conjunctiva and subconjunctival tissue, of triangular 
shape, and more or less markedly vascular, which ex- 
hibits a tendency to encroach upon the cornea. The 
apex of the growth is always turned toward the center 
of the cornea; the base toward the equator of the eye- 



I96 PREVALENT DISEASES OF THE EYE. 

ball (Plate IV, Fig. 2). Its usual location is to the 
nasal side of the cornea, over the region of attachment 
of the tendon of the internal rectus muscle; exception- 
ally it is situated upon the outer side of the cornea. It 
develops very slowly, and months, or even years, may 
elapse without its extending far enough upon the cornea 
to impair vision. It is rarely met with in children, 
and it is more prevalent in tropical than in temperate 
countries. 

The apex of a pterygium occasionally reaches, but 
very rarely passes beyond, the center of the cornea. 
I have, however, met with one case in which a ptery- 
gium of unusually large size, starting from the nasal 
side of the eye, grew entirely across the cornea to its 
external margin. The other eye of the same individual 
(a woman advanced in years) also exhibited a large 
pterygium, which already had passed beyond the center 
of the cornea. As long as the growth is confined to 
the conjunctiva and the periphery of the cornea it 
causes little or no inconvenience, apart from its un- 
sightliness. When, however, it encroaches upon the 
pupillary area of the cornea it seriously impairs vision, 
not only by obstructing the passage of light into the 
eye, but because the curvature of the corneal surface 
about its apex is so altered as to produce a high grade 
of irregular astigmatism. 

The question of the etiology of pterygium has been 
much discussed, and several theories have been ad- 
vanced to account for its occurrence and for its growth. 
In order to a clear comprehension of the matter, it is 
essential that a sharp distinction should be drawn be- 
tween true pterygium, which so far we have been con- 
sidering, and pseudo-pterygium, since much of the 
confusion regarding the etiology of this affection has 
arisen from failure to do this. 



DISEASES OF THE CONJUNCTIVA. 197 

Pseudo-pterygium, which is as apt to develop at the 
upper or lower margin of the cornea as in any other 
direction (whereas true pterygium may be said never 
to occur in either of these positions), has its starting- 
point in the presence of an ulcer or wound of the 
cornea near its margin, to which a knuckle of the 
swollen and overhanging conjunctiva becomes adher- 
ent. Occasionally, in this variety of pterygium, 
which is a not very uncommon consequence of gonor- 
rheal conjunctivitis, and, as just indicated, of marginal 
wounds of the cornea, only the apex of the growth is 
adherent to the cornea, and it is possible to pass a 
probe under the body of the pterygium. It is mani- 
fest, therefore, that both clinically and etiologically this 
affection differs radically from true pterygium. 

It has long been taught that the development of true 
pterygium, like that of pinguecula, is favored by 
conditions which bring about persistent hyperemia of 
the conjunctiva, as, for example, exposure of the eyes 
to the rays of a tropical sun, as in long sea voyages, or 
to the heat from furnaces or to the irritant action of 
dust and vapors, as in mills and other manufacturing 
establishments; and the evidence in favor of this view 
is much too strong to be put aside. Fuchs, indeed, 
holds that a pterygium is simply a pinguecula which 
has extended onto the cornea, and in doing so has 
drawn the conjunctiva after it. While it is undoubt- 
edly true that pterygium not infrequently does originate 
in this manner, the view that it always does so is not, 
I believe, supported by clinical observation. Transi- 
tional types, which one observer might call pterygium, 
and another pinguecula, are often encountered. 

Any theory which would satisfactorily explain the 
origin of pterygium must, it seems to me, account for 



I98 PREVALENT DISEASES OF THE EYE. 

the fact that in a large majority of instances the growth 
develops to the nasal side of the cornea, over the region 
of the internal rectus muscle. This the theory which 
I advanced some years ago — that insufficiency of the 
internal recti muscles (exophoria), by inducing hyper- 
emia of the overlying conjunctiva, is an important 
factor in the causation of pterygium — does in an emi- 
nently satisfactory manner.* In the years that have 
elapsed since this view was advanced, the frequency 
with which I have found these two conditions — ptery- 
gium and exophoria — associated, has convinced me 
that it is not without substantial foundation. 

Treatment. — In jhe treatment of pterygium little is 
to be expected except from operative interference. 
However, in its incipient stage its growth may be re- 
tarded, or possibly arrested, by the correction of any 
muscular anomaly or error of refraction which may be 
present; and it may be added that after operation 
the tendency to recurrence may be controlled in the 
same way. In this connection it should be observed 
that the discomfort (asthenopia) of which persons with 
pterygium often complain, is much more apt to be due 
to the existence of a muscular or refractive error than 
to the mere presence of the growth. 

The propriety of resorting to operation depends upon 
several considerations. When the growth, though con- 
fined to the conjunctiva, is narrow and well-defined, 
it is advisable to operate; but if it is broad and ill- 
defined, it is well not to interfere, unless it is known 
to be progressing, because, under such circumstances, 
there is no assurance that the condition and appear- 

* See "Trans. Am. Ophthalmolog. Soc," Vol. IV, p. 537; "Am. 
Journal Ophthalmology," Aug., 1887; and "Reference Handbook 
of the Medical Sciences," Vol. VI, p. 58. 



DISEASES OF THE CONJUNCTIVA. I99 

ance of the eye will be better after operation than it 
was before. When, already, the growth has encroached 
upon the cornea, it is best not to postpone operation, 
for when this has happened it usually continues to 
advance, and as it does so produces changes in the 
corneal structure of such character as to leave a more 
or less pronounced permanent opacity, even when it 
has been removed with the greatest care. 

Of the many operative procedures which have been 
proposed for the cure of pterygium, the operation of 
excision is the only one which I am disposed to com- 
mend. The end which all of these procedures seek to 
accomplish is the same — to minimize the loss of con- 
junctival tissue — and this, indeed, is of the first impor- 
tance; but when excision is properly performed there 
need be but little sacrifice of tissue. The important 
point to bear in mind is that while the corneal portion 
of the growth should be carefully dissected up and com- 
pletely removed, the conjunctival portion should be 
dealt with much less radically, should, indeed, be only 
in part removed. If this precaution is not observed, a 
large gap will be made in the conjunctiva, and after the 
completion of the healing process, which under such 
circumstances is apt to be slow and difficult, a con- 
spicuous, vascular cicatrix will be left, which may 
interfere with the free movements of the eyeball, and 
which is as unsightly as was the pterygium itself. 

The method of operating which I have employed 
for years, and which, as a rule, has yielded very satis- 
factory results, recurrence of the growth being decidedly 
exceptional, is as follows: With a pair of slender, 
toothed forceps (such as are used in operating for 
squint) the pterygium is seized near its apex, and, 
while considerable traction is made upon it, is carefully 



200 PREVALENT DISEASES OF THE EYE. 

dissected from the cornea with a sharp and but slightly 
bent iridectomy knife, especial care being taken to 
detach its margins from the corneal limbus; its more 
loose attachments to the sclera are also divided for 
a distance of 3 or 4 mm. from the border of the cornea. 
Then with a pair of slender scissors, curved on the 
flat, the whole of the corneal and a small part of the 
conjunctival portion of the growth is excised by two 
converging cuts. During this step of the operation 
but slight traction is exerted with the forceps; for, if 
the traction is considerable, and if at the same time 
the scissors are pressed against the sclera, a much 
larger part of the pterygium will be removed than is 





a b 

Fig. 83. — Operation for the removal of pterygium. The dotted 
lines (a) represent the portion of the growth which is excised; b represents 
the conjunctival wound closed by two stitches. 

desirable. The margins of the conjunctival wound 
are now slightly undermined with the scissors, so that 
they may be more readily brought together by two su- 
tures of fine black silk, which are next introduced (Fig. 
83). A light bandage is then applied, to be worn until 
the stitches are removed on the second or third day, 
when a collyrium of boracic acid (ten to twelve grains 
to the ounce) is prescribed, to be used until the inflam- 
mation consequent upon the operation has subsided. 
A speculum should, of course, be used during the 
operation, and the eye should be thoroughly under the 



DISEASES OF THE CONJUNCTIVA. 201 

influence of cocain. The instillation of a few drops of 
a i : iooo adrenalin solution is also of advantage, as 
it renders the operation nearly, if not quite, bloodless. 

It is well to inform the patient that the improvement 
in the appearance of the eye will be slow, else he may 
suppose the operation has not been successful, and 
may mistake the localized vascularity, which remains 
for some time, for a return of the growth. 



CHAPTER VI. 

DISEASES OF THE CORNEA AND SCLERA. 

Diseases of the Cornea, 
keratitis. 

Inflammation of the cornea, keratitis, occurs 
as a primary and as a secondary condition. As a 
secondary condition it is oftenest observed in associa- 
tion with the severer forms of conjunctivitis. It may 
be acute or chronic in type, may involve one or both 
eyes, may be wholly dependent upon local causes or 
may be constitutional in its origin, and it is, not infre- 
quently, a result of traumatism. It is commonly 
accompanied by pericorneal subconjunctival and con- 
junctival injection, a contracted pupil, and by more or 
less marked impairment of the transparency of the 
cornea and loss of its surface luster. In some forms 
of keratitis the development of blood-vessels upon or 
in the cornea is a striking feature. It is usually at- 
tended by pain, often very severe, and by photophobia 
and lacrimation. There may be also marked impair- 
ment of vision if the corneal opacity is dense and over- 
lies the pupil. 

The several varieties of keratitis may be grouped 
conveniently under two heads — suppurative keratitis 
and nonsuppurative keratitis. To the former group, 
characterized by a tendency to tissue necrosis, belong 
phlyctenular keratitis, abscess and ulcer of the cornea, 
keratomalacia, and, as a rule, neuropathic keratitis; 
to the latter, interstitial keratitis, pannus or pannitic 



DISEASES OF THE CORNEA AND SCLERA. 203 

keratitis, and certain comparatively rare forms of 
corneal inflammation — sclerosing keratitis and kera- 
titis profunda — which need not engage our attention, 
the chief characteristic of this group being chronicity. 

The dangers to be feared in keratitis are extensive 
necrosis of the corneal tissue, circumscribed necrosis, 
as in perforating ulcer, the formation of permanent 
opacities, which may seriously impair sight, and altera- 
tions in the shape of the cornea, which are scarcely less 
detrimental to vision (Fig. 84). The control of the in- 




Fig. 84. — Keratectasia resulting from an ulcer. Magnified 25 X i 
(Fuchs). The thinned and protruding cicatrix is distinguished by its 
denser texture from the adjacent normal cornea. The epithelium, e, 
over it is thickened, while Bowman's membrane, b, is wanting. On the 
other hand, Descemet's membrane, d, with its endothelium, is everywhere 
present— a proof that the ulcer has not perforated. 



flammatory process as quickly as possible, so that the 
serious consequences just enumerated may not occur, 
and the relief of the attendant pain and photophobia, 
are the ends to which treatment should be directed. 

The corneal epithelium (Fig. 85) when destroyed by 
accident or disease, it may be remarked, is quickly re- 
generated; but, on the other hand, Bowman's membrane 
is never regenerated, and the true corneal tissue (the 
substantia propria of the cornea) when lost is replaced 
by connective tissue, which seldom attains the transpar- 



204 



PREVALENT DISEASES OF THE EYE. 



ency of the normal cornea, though it is the fixed cor- 
neal cells which are mainly instrumental in its forma- 
tion (Fig. 86). 

SUPPURATIVE KERATITIS. 

In the production of the different forms of sup- 
purative keratitis bacteria play an important role. 




Fig. 85.— Section of cornea (Piersol): a, Anterior epithelium; c, 
anterior limiting (Bowman's) membrane; b, b, fibrous stroma of substantia 
propria, containing corneal corpuscles (/) lying within the corneal spaces; 
d, posterior imiting (Descemet's) membrane; e, endothelium lining an- 
terior chamber. 

Those oftenest concerned are the Staphylococcus 
aureus, the streptococcus and the pneumococcus. The 
infection usually is ectogenous, though in many in- 
stances undoubtedly it is entogenous. The tractability 
or intractability of this type of keratitis depends upon 



DISEASES OF THE CORNEA AND SCLERA. 



205 



the micro-organism concerned in its production — the 
pneumococcus, for example, giving rise usually to a 
severe form of keratitis — and the bactericidal energy of 
the cells and the body juices which the invading bac- 
teria must encounter. The worst cases, unquestion- 
ably, are those in which the more virulent bacteria play 
a part, and, from one cause or another, meet with 
exceptionally feeble resistance. 
Phlyctenular Keratitis or Kerato-conjunctivi- 




Fig. 86. — Cicatrix of the cornea (Saemisch). The epithelium, e, 
is everywhere present, but over the cicatrix it is irregular, and in places 
(at a) is thickened. Bowman's membrane, b, is wanting at the site of the 
cicatrix. The latter itself is distinguished from the tissue of the normal 
cornea by its denser and less regular texture. 



tis. — In treating of phlyctenular conjunctivitis it was 
stated that, as often as not, the cornea is involved as 
well as the conjunctiva in this type of ophthalmia (Fig. 
87). It was stated also that when this is the case the 
photophobia and lacrimation are commonly more pro- 
nounced, and, further, that it is through this involve- 
ment of the cornea that the sight is at times perma- 
nently impaired, the impairment of sight being caused 
either by the formation of a persistent corneal opacity 
or, in the case of an ulcer perforating into the anterior 



206 



PREVALENT DISEASES OF THE EYE. 



chamber, by the development of an anterior synechia 
and the consequent displacement or obliteration of the 
pupil (Fig. ioo). 

As to treatment, it was pointed out that when the 
involvement of the cornea is attended, as it often is, 
by pronounced photophobia and lacrimation, a con- 
siderable stronger solution of atropin (gr. ij-iv to 5j) 
than is commonly used when the inflammation is con- 
fined to the conjunctiva should be employed. 

Since the two conditions, phlyctenular conjunctivitis 




Fig. 87. — Section of corneal phlyctenule: b, Bowman's membrane; c, 
corneal substance; d, Descemet's membrane; e, epithelium; /, phlyctenule, 
consisting of a deposit of round-cells in the epithelial layer and along the 
course of the nerve; n, twig of nerve ending in epithelium (modified from 
Iwanoff). 



and phlvctenular keratitis, are essentially the same 
not only in their etiology but, except in the particulars 
just pointed out, in their clinical history and their treat- 
ment as well, there remains but little to be added re- 
garding the latter condition, except to say that when 
a threatening ulcer has taken the place of the super- 
ficial ulcer usually left by the breaking down of a 
phlyctenule, the therapeutic measures recommended 
in corneal ulcers having a different origin — the liberal 
administration of quinin being one of the most impor- 
tant — are indicated. 



DISEASES OF THE CORNEA AND SCLERA. 



207 



Abscess and Ulcer of the Cornea. — In nonsuppur- 
ative keratitis the inflammatory infiltrate, which charac- 
terizes all types of corneal inflammation (Fig. 88), dis- 
appears more or less completely without the formation 
of pus and without necrosis of the corneal stroma. 
In suppurative keratitis, on the other hand, the infiltrate 
breaks down, pus is formed, and to a greater or less 
extent necrosis of the corneal tissue occurs. When 
this pus formation and this tissue necrosis take place 
in the superficial layers of the cornea, we have a corneal 




Fig. 88. — Infiltrate in the cornea; first stage of keratitis (Saemisch). 
The epithelium, e, and Bowman's membrane, b, over the infiltrate are 
preserved. 



ulcer; when they occur in the deeper layers, and are 
shut in, in front and behind, by tissue which is rela- 
tively sound, an abscess of the cornea. 

As a rule, a corneal abscess tends to become con- 
verted into an ulcer through breaking down of the 
overlying corneal substance. Exceptionally, the under- 
lying tissue breaks down, and the abscess discharges 
into the anterior chamber; while in other instances the 
pus burrows extensively between the corneal layers, 
and shows little disposition to make toward either the 
anterior or the posterior surface of the cornea. 



208 PREVALENT DISEASES OF THE EYE. 

As may be inferred from this description, abscess 
and ulcer of the cornea are alike in their etiology, and 
differ but little in the symptoms which attend them. 
Among their commoner causes may be mentioned 
traumatism, complicated by bacterial infection; puru- 
lent conjunctivitis; blennorrhea of the lacrimal sac; 
abnormal exposure of the cornea, such as may result 
from paralysis of the orbicularis muscle; a lowered 
state of the general system, as after typhoid fever or 
the exanthematous fevers; auto-infection, from the 
alimentary canal especially; senility; and disturbances 
in the nerve-supply of the cornea, having their origin 
usually, it seems probable, in the gasserian or in the 
ophthalmic ganglion. 

A moment's reflection will show that the mode of 
action of these various causes is essentially the same; 
that they all — the traumatism, the neuro-paralysis, the 
lowered vitality of the system, etc. — pave the way for 
successful bacterial invasion of the corneal tissue. 

The symptoms common to the two conditions are 
pain, often very severe, and referred not only to the 
eye but to the brow, temple, and side of the head, 
photophobia, lacrimation, and blepharospasm. Ex- 
ceptionally, especially in the aged, an ulcer may de- 
velop in the cornea without attendant pain or photo- 
phobia. Inspection of the eye shows circumscribed 
opacity of the cornea, marked conjunctival injection, 
more pronounced in the neighborhood of the ulcer or 
abscess, a contracted pupil, frequently decided edema 
of the lids, slight muco-purulent discharge, and in the 
more unfavorable cases hypopyon — a collection of pus 
or of fibrin and round cells in the lower part of the 
anterior chamber (Plate V, Fig. i). In the case of an 
abscess, the opacity will be beneath the surface of the 



PLATE V. 




Fig. i. — Corneal Ulcer, with Hypopyon. 




•-> • l/i Co h> o \ S, 



Fig. 2. — Interstitial Keratitis. 



DISEASES OF THE CORNEA AND SCLERA. 200, 

cornea, which will be seen to be intact. If an ulcer be 
present, there will be a manifest loss of substance, an 
excavation, which may be shallow or deep, and vary 
greatly in extent. 

Much may be learned as to the condition of a corneal 
ulcer by careful inspection, especially with the aid of ob- 
lique illumination. If it be in a progressive stage, its 
walls will be opaque and its edges ragged and somewhat 
undermined (Fig. 89); if in a regressive stage, if the re- 




Fig. 89. — Corneal ulcer in progressive stage (Saemisch). The base 
of the ulcer is formed by an accumulation of pus cells, which also push 
their way some distance in between the lamellae of the cornea that adjoin 
the ulcer. At the edges of the ulcer, which are somewhat raised, the 
epithelium, e, and Bowman's membrane, b, end as if cut short off. 

parative process has been established, it will present a 
cleaner appearance, its walls will be nearly transparent, 
and its edges rounded off (Fig. 90), and, especially if 
it be near the corneal border, newly formed, superficial 
blood-vessels will, perhaps, be seen running to its margin 
from the neighboring conjunctiva. 

There is a vast difference in the behavior and in the 

tractability of corneal ulcers. In some instances they 

are uncontrollable, and tend to go from bad to worse 

in spite of all that can be done to combat them; in 

14 



210 



PREVALENT DISEASES OF THE EYE. 



others, they show a disposition to do well, and respond 
promptly and favorably to treatment. It is usual to 
denominate ulcers of the former type "infected" ulcers, 
and those of the latter, "simple" ulcers; but this nomen- 
clature is open to objection, for even the mildest ulcers 
are "infected," in the sense that bacteria nearly always 
play a part in their production. 

We have yet much to learn regarding the etiology and 
pathology of corneal ulcers; but enough already is known 




Fig. 90. — Corneal ulcer in regressive stage (Saemisch). The base 
of the ulcer is formed by the denuded lamellae of the cornea; a slight in- 
crease in the number of cells between them can still be made out. At the 
edges, b, of the ulcer the epithelium, e, is beginning to grow out over the 
base. Newly formed blood-vessels (g) lying in the upper layers of the cor- 
nea run to the ulcer. 



to warrant the statement that their malignancy does not 
depend upon the mere presence of bacteria, but rather 
upon the nature of the bacteria and, scarcely to a less 
degree, upon the character of the opposition — feeble or 
energetic — which they encounter in their invasion of the 
corneal tissue. When, in consequence of lowered general 
vitality or of unusual local conditions, this resistance is 
exceptionally inefficient, even the less virulent bacteria, 
such as the Staphylococcus pyogenes aureus, may do 
irreparable damage; but usually when the infection is of 



DISEASES OF THE CORNEA AND SCLERA. 211 

this character the ulcer is benign and not difficult to 
control. On the other hand, when there is a strepto- 
coccus infection, or when the pneumococcus or the Klebs- 
Loffler bacillus is present, the ulcer is apt to exhibit 
greater malignancy, and to tax our therapeutic powers. 

Systematic writers upon diseases of the eye com- 
monly speak not only of "simple" and "infected" 
ulcers, but they describe several kinds of "infected" 
ulcers, to which they give particular names, such as 
serpent or acute sloughing ulcer, marginal or ring ulcer, 
herpetic or dendritic ulcer, and hypopyon ulcer. It 
would serve no useful purpose to describe and consider 
each of these at length; but it may be stated briefly 
that the serpent ulcer, which shows a tendency to 
progress in a tortuous course upon the cornea, is often 
of traumatic origin, is usually attended by hypopyon, 
and is especially dangerous, causing loss of sight 
not infrequently through involvement of the deeper 
structures of the eye; that the ring ulcer, which tends 
to encircle the cornea close to its margin, often proves 
intractable, and in the worst cases may lead to blindness 
through complete necrosis of the cornea; and that the 
dendritic ulcer — named because of its fancied resem- 
blance to a fern leaf, and also called mycotic ulcer, 
because in some instances it has been found to be 
infected with a fungous growth — is obstinate in charac- 
ter, owing to its herpetic origin is not infrequently 
attended bv anesthesia of the cornea and by marked 
ciliary irritation, is met w T ith at times as a sequel of 
malarial fever, and is prone to leave in its wake a much 
more persistent and conspicuous opacity than the slight 
loss of substance which commonly attends it would 
lead one to expect. 

Treatment. — In the treatment of abscess and ulcer 



212 PREVALENT DISEASES OF THE EYE. 

of the cornea constitutional measures are scarcely of 
less importance than local measures. By means of 
constitutional measures it is possible to strengthen the 
combative powers of the cornea, and, when the infection 
is entogenous, to rid the system, in large measure 
perhaps, of the bacteria and their toxins which are 
responsible for the local malady. By the use of local 
applications we are able to enfeeble or destroy the 
bacteria at their point of attack, and to put the eye 
in the most favorable condition to resist their destruc- 
tive action. 

Quinin, in liberal doses, is the constitutional remedy 
of greatest value, since, perhaps by increasing the phago- 
cytic action of the cells or the bactericidal energy of the 
body iuices, it unquestionably reinforces the resisting 
power of the cornea.* An energetic calomel purge is the 
agent which, by unloading the alimentary canal, ac- 
complishes most toward ridding the system of bacteria 
and their poisonous products. 

The most useful local remedies are atropin, holocain, 
dionin, occasionally eserin, and, as bactericides, boracic 
acid, yellow oxid of mercury, chlorin water, carbolic acid, 
curettage, and, under exceptional circumstances, the 
actual cautery. The opium and boracic acid lotion, 
which has been mentioned so often, is a valuable ad- 
juvant. In benign ulcers, such, for example, as occur 
in phlyctenular keratitis, a one-grain solution of atropin, 
with the addition of boracic acid (gr. x-xv to 5j), applied 
three to four times a day, and supplemented by the daily 
application of yellow oxid of mercury ointment (gr.j 
to vaselin oj), is in most instances efficacious. Chlorin 
water, which should be of full strength and freshly 

* Mercury, given so as to impress the system, produces exactly 
the opposite effect. 



DISEASES OF THE CORNEA AND SCLERA. 213 

prepared, is a valuable remedy in less benign ulcers, 
especially those of traumatic origin. Its application 
causes little or no discomfort, and it should be dropped 
into the eye freely every two or three hours, being used 
in conjunction with atropin or holocain. 

The existence of pain, photophobia, and lacrimation 
is an indication for employing a strong solution of 
atropin (gr. iv to gj)- Holocain (the hydrochlorate) is 
used in one- to two-grain solution, and with this also 
it is well to combine boracic acid. It should be ap- 
plied once in three hours. It may be used instead of 
atropin, when the latter does not act favorably, or in 
conjunction with it. It relieves pain, and promotes 
the healing of the ulcer, partly, at least, by favoring 
the formation of new blood-vessels upon the cornea. 
Although an anesthetic, it does not, like cocain, dilate 
the pupil or disturb the corneal epithelium. Dionin, 
which, in conjunction with atropin or holocain, may be 
used in five per cent, solution, as often as three times a 
day, not only relieves pain, but furthers the process of 
repair and the absorption of inflammatory products 
through its stimulant action upon the lymph currents 
of the eye. The lotion of opium (ext. opii, gr. x-xv; 
acid, boracic, gr. xl-lx; aquae destil., 5iv), if accept- 
able to the eye, should be used freely, being applied 
more or less constantly to the closed lids upon a gauze 
or linen pad. Eserin is indicated, in my judgment, only 
when there is increased intraocular tension, and, because 
of its tendency to produce iritis, it should be used with 
caution and only in weak solution (gr. J— j to Sj). 

In ulcers that are foul and show a disposition to 
extend carbolic acid, in full strength, carefully applied 
directly to the ulcer, and usually preceded by cautious 
curetting, often accomplishes great good, changing the 



214 PREVALENT DISEASES OF THE EYE. 

character of the ulcer, and inducing the process of 
repair. To facilitate the application the eye should 
be thoroughly cocainized, which renders the procedure 
painless. The application may be made conveniently 
by means of a finely pointed wooden toothpick, about 
the tip of which a few fibers of absorbent cotton have 
been wound. If much cotton is used, an excess of the 
acid will be taken up, and it will be almost impossible 
to prevent its spreading over healthy portions of the 
cornea. The acid should be applied to the ulcer thor- 
oughly by a gentle rubbing movement, which is, in 
effect, a sort of curettage. If the ulcer is lined by 
infected and necrotic material, this should be removed 
with a small curet before the application of the acid. 
When, however, this condition is less pronounced, aided 
by the loosening action of the cocain, the cleaning of 
the ulcer may be effected satisfactorily by means of a 
toothpick, armed with a wisp of dry absorbent cotton. 
After the acid has been allowed to remain in contact 
with the ulcer for a few moments, the lids meantime 
being held apart, its further action should be arrested 
by flushing the cornea with sterile water, normal salt 
solution, or a saturated solution of boracic acid. Some 
smarting may be felt in the eye after the effect of the 
cocain has passed off, but usually this is not pronounced. 
The application may be repeated after twenty-four 
hours, should the ulcer still present a foul appearance. 
The timely employment of carbolic acid in the careful 
manner just described will reduce to a minimum the 
cases in which resort to the actual cautery will be de- 
manded. However, when the condition of the ulcer 
is not improved by the application of the acid, or when 
the ulcer is extending rapidly and perforation of the 
cornea is imminent, the actual cautery should be em- 



DISEASES OF THE CORNEA AND SCLERA. 215 

ployed. The galvanocautery, provided with a very 
delicate platinum tip, is best adapted for the purpose. 
So energetic an agent, however, should be employed 
only by those skilled in its use, since in untrained hands 
it is apt to do irreparable damage to the delicate struc- 
tures of the eye. 

Paracentesis of the anterior chamber for the purpose 
of removing the hypopyon, which, as has been said, is 
often present in the more malignant types of corneal 
ulcers, and incision of corneal abscesses with a view 
of giving vent to the insignificant amount of pus which 
they commonly contain, are procedures of doubtful 
value, which were formerly more in vogue than they 
are at present. The traumatism involved, more espe- 
cially in the first-mentioned procedure, seems not infre- 
quently to turn the scales, and to hasten the impending 
total necrosis of the cornea. However, an abscess 
which is extending laterally, and shows no disposition 
to reach the surface, should be opened by the removal 
of the overlying corneal tissue with a curet, and should 
then be treated as one would treat a malignant ulcer — 
by the application of carbolic acid or the galvano- 
cautery. 

Keratomalacia. — As the name indicates, this is a 
softening or sloughing of the cornea. Though not one 
of the commoner diseases of the eye, it has seemed to 
me to demand, at least, brief consideration, since it is 
a malady which the general practitioner may be called 
upon at any time to recognize and treat. It is a con- 
dition rarely met with except in children, and occurs 
in them as a result usually of some exhausting disease, 
such as scarlet fever, measles, typhus fever, or inherited 
syphilis, or as a consequence of malnutrition from 
insufficient or improper food. It is attended by none 



2l6 PREVALENT DISEASES OF THE EYE. 

of the usual symptoms of corneal inflammation, such 
as pain, photophobia, and lacrimation; indeed, dimin- 
ished lacrimation is a feature of the disease. It is 
frequently preceded by night-blindness, which is simply 
another manifestation of the lowered general vitality, 
and by desiccation of the corneal and conjunctival 
epithelium. It commonly affects both eyes, and the 
necrotic process, which is clearlv the result of unop- 
posed bacterial invasion, may progress so rapidly as to 
cause complete destruction of the corneae within a few 
hours. (See Fig. 66.) It is accompanied by pericor- 
neal, venous injection of a duskv red color. 

Fortunatelv, the children attacked bv this terrible 
maladv seldom long survive the ocular involvement, 
but die from general exhaustion or from some inter- 
current affection, such as pneumonia or bronchitis. 

Treatment. — This is of little avail after the corneal 
necrosis has commenced. The indications are to im- 
prove the general condition of the child by every means 
possible — bv nourishing diet, stimulants, and tonics, 
quinin especiallv, and to apply soothing and antiseptic 
remedies to the eyes, atropin, in weak solution, or holo- 
cain, and chlorin water or a saturated solution of 
boracic acid. If the case is seen before the cornea has 
begun to break down, during the period of night- 
blindness and conjunctival desiccation, the energetic 
employment of the measures indicated may prevent 
the loss of sight. 

Neuropathic Keratitis. — This variety of keratitis, 
that is to say, keratitis dependent primarilv upon disorder 
of the nerve-supply of the cornea, is, in my opinion, of 
much more frequent occurrence than is commonly sup- 
posed. The more severe types of this affection, such 
as arise from serious lesions of the fifth nerve or of the 



DISEASES OF THE CORNEA AND SCLERA. 217 

gasserian ganglion, it is true, are not common; but the 
milder forms, characterized by more or less pronounced 
anesthesia of the cornea, and having their origin, prob- 
ably, in pathological changes in the ophthalmic gang- 
lion, are often encountered. Doubtless in some cases of 
corneal inflammation originating in this manner 
bacteria play a part, — an important part in those which 
are attended by suppuration and considerable loss of 
corneal substance, — but the prime factor in the pro- 
duction of this type of keratitis is the disturbance in the 
metabolism of the cornea due to the derangement of 
its nerve-supply. Probably the sympathetic fibers 
which pass from the ophthalmic ganglion to the eye 
have most to do with this disturbance; but, at all 
events, the sensory fibers, as well, usually are involved, 
as is shown by the corneal anesthesia. 

Keratitis from Lesions of the Ophthalmic Division of 
the Fifth Nerve, its Nucleus, or the Gasserian Ganglion. 
— In serious lesions of the ophthalmic division of the 
fifth nerve or its nucleus, or of the gasserian ganglion, 
severe and rapidly destructive inflammation of the 
cornea at times occurs. Under such circumstances we 
first observe a lack of luster, quickly followed by des- 
quamation, of the corneal epithelium. Then the anes- 
thetic cornea, which, owing to the lessened activity of 
the lacrimal gland, is not bathed and moistened by the 
tears as it is under normal conditions, becomes cen- 
trally clouded and then, perhaps, rapidly necrotic. 

The view, widely held, that this is a purely traumatic 
inflammation, due to injuries received in consequence 
of the want of sensibility of the cornea, always has 
seemed to me chimerical. A more reasonable ex- 
planation, as has already been suggested, is that owing 
to its deranged metabolism the cornea is in a state of 



2l8 PREVALENT DISEASES OF THE EYE. 

unstable equilibrium, so to speak, — a state in which, 
with all other conditions favorable, its vitality is hardly 
maintained. Under such circumstances, with the 
corneal epithelium denuded, the conditions are ideally 
favorable for destructive bacterial action; so that even 
the less virulent micro-organisms that are not infre- 
quently present in the conjunctival sac, and that 
usually are harmless, are now able to overcome the 
feeble resistance opposed to them, and to cause destruc- 
tion of the corneal tissue. 

Herpes Zoster Ophthalmicus. — Another severe type 
of neuropathic keratitis, which fortunately, like that 
just described, is not common, is that which is met 
with in herpes zoster ophthalmicus. Here, as is well 
known, the primary lesion is in the gasserian ganglion. 
Usually in this affection the ocular inflammation 
is not limited to the cornea, but involves the iris and 
at times the deeper portions of the uveal tract as well. 

The keratitis of herpes zoster, which is almost 
always unilateral, is usually obstinate, deep-seated, and 
attended bv severe pain and pronounced photophobia. 
At the outset vesicles, commonly in groups, make their 
appearance upon the cornea. These rupture early, 
and leave superficial ulcers, which may extend deeply 
into the corneal tissue. Anesthesia of the cornea, as 
well as of the lids and forehead, is present. The one- 
sided eruption upon the upper lid, forehead, and scalp, 
and less frequently upon the side of the nose, is char- 
acteristic, and indicates the true nature of the affec- 
tion (Fig. 91). Perforation of the cornea rarely occurs, 
but indelible opacities are frequently left, which 
may seriously and permanentlv impair sight. 

The milder forms of neuropathic keratitis, under which 
head I would include herpes corneae febrilis, post- 



DISEASES OF THE CORNEA AND SCLERA. 



2K 



malarial keratitis, and dendritic keratitis, are, as has 
been said, of frequent occurrence. They appear to arise 
from a variety of causes, and often occur without assign- 
able reason. They are characterized by more or less 
pronounced anesthesia of the cornea; may be attended 
by the formation of vesicles, by superficial ulceration or 
simply by inflammatory infiltration; are inclined to be 
intractable; are almost invariably monocular, and are 
apt to leave persistent opacities, out of proportion to the 
loss of tissue which attends them (Fig. 92). Among 




Fig. 91. — Herpes zoster ophthalmicus 
(Posey and Wright). 



Fig. 92. — Herpetic (neuropatnic) 
keratitis (Haab). 



their known causes may be mentioned "cold," malarial 
fever, influenza, bronchitis, pneumonia, typhoid fever, 
reflex dental irritation, and probably rheumatism, 
gout, and syphilis. 

I have long believed, though I have no definite evi- 
dence to offer in support of this belief, that the primary 
lesion in these types of keratitis is in the ophthalmic 
ganglion. That, in fact, we have here a condition 
closely related to herpes zoster ophthalmicus, the 
difference being that in one case, the primary lesion 



220 PREVALENT DISEASES OF THE EYE. 

being in the gasserian ganglion, the resultant inflam- 
matory changes and the attendant anesthesia manifest 
themselves not only in the eye but in other regions — 
the lid, forehead, etc. — supplied by the fifth nerve; 
while in the other, in which the original fault is in 
the ophthalmic ganglion, the consequent inflammation 
and anesthesia, as might be expected, are limited to 
the eye itself. A significant fact, worthy of mention 
in this connection, is that malarial fever, which is one 
of the most definitely proved causes of the type of 
neuropathic keratitis w T e are considering, is also a 
recognized cause of herpes zoster. The unilateral 
character of both affections is also significant. 

Post-malarial Keratitis. — One of the most typical 
examples of the milder variety of neuropathic keratitis 
is that which follows malarial fever. In this affection, 
which is unilateral, and is attended by marked ciliary 
irritation, — pain, photophobia, and lacrimation, — we 
have impairment of corneal sensibility and superficial 
inflammatory infiltration and ulceration, the ulcer 
showing but little tendency to spread, and often exhibit- 
ing a branched or arborescent form. Closely related 
to this, frequently not to be distinguished from it, and 
in many instances, probably, identical with it, is the 
so-called dendritic keratitis. The close resemblance 
of these two affections, for they are alike not only in 
appearance but in general behavior, is to be attributed, 
I believe, to the probable fact that, whatever the 
inducing cause, each has its origin in disease of the 
ophthalmic ganglion. The characteristic feature of 
herpes cornece febrihs, another nearly related affection, 
attended by impaired sensibility of the cornea and 
almost without exception unilateral, is the appearance at 
the outset of the attack of numerous small vesicles, 



DISEASES OF THE CORNEA AND SCLERA. 221 

which soon rupture, leaving superficial ulcers, that not 
infrequently present the same dendritic or arborescent 
form just spoken of.* 

Treatment. — In the treatment of neuropathic kera- 
titis, as may be inferred from what has been said as to 
its etiology, constitutional as well as local remedies are 
called for. The most useful local remedy, indicated in 
all of its forms, is atropin, with which it is well to com- 
bine boracic acid. Depending upon the amount of 
pain, photophobia, etc., present, the strength of the 
solution prescribed should vary from one to four 
grains to the ounce. Holocain, in one-grain-to-the- 
ounce solution, is also useful, and so is the lotion of 
opium and boracic acid. When, in the ulcerative 
forms, secondary bacterial infection is found to have 
occurred, chlorin water, employed as recommended 
in other intractable corneal ulcers, is valuable, and 
under such circumstances it may become necessary to 
resort to curettage and the application of pure carbolic 
acid. 

In the severe type of neuropathic keratitis which 
results from lesion of the fifth nerve or its nucleus one 
of the most important measures is to keep the lids 
constantly closed by a light and evenly applied ban- 
dage, so as to afford the eye as complete protection as 
possible. In herpes zoster ophthalmicus the syste- 
matic use of atropin in strong solution (gr. iv to 5j) 
is especially indicated, not only on account of the 
severe pain which commonly attends it, but because of 
the danger that iritis may develop at any time. 

The most valuable constitutional remedy is quinin, 

* Fuchs, than whom, on such a point, there is scarcely a higher 
authority, seems not disposed to make a distinction between herpes 
corneae febrilis and keratitis dendritica. 



222 PREVALENT DISEASES OF THE EYE. 

which should be given with sufficient freedom — three 
grains, four or five times a day — to produce moderate 
cinchonism. Its usefulness is by no means confined 
to the post-malarial type of neuropathic keratitis, but 
is manifested in all varieties of the affection. Strych- 
nin, which may be given in association with the quinin, 
is useful also, and iron should be prescribed when the 
condition of the system seems to call for it. Arsenic, 
a remedy often recommended, I have found rather 
disappointing in its effect. Next to quinin, I am dis- 
posed to regard potassium iodid as the drug most 
apt to accomplish good. In prescribing it I have had 
in view its effect upon the hypothetical lesion of the 
ophthalmic ganglion — for it is especially in the milder 
forms of neuropathic keratitis that it has proved effica- 
cious — rather than any direct influence which it might 
exert upon the keratitis itself. It should be given in 
five- to ten-grain doses, three times a day. Salicylic 
acid is another remedy which has been recommended, 
especially in herpes zoster ophthalmicus (Leber); but 
as to its value I can not speak from experience. 

The possibility that an intractable keratitis of the 
type under consideration may be due to reflex dental 
irritation should not be lost sight of. Such cases, 
doubtless, are not common; but that they do occur I 
am convinced. "Dead" teeth, always, it would seem, 
on the side of the eye affected and usually in the upper 
jaw, are more apt to produce such consequences. If, 
therefore, such teeth, or others badly carious, are found 
to be present, and especially if they are painful or 
sensitive to pressure, they should be extracted without 
unnecessary delay. From this measure I have seen 
benefit result too often to leave any doubt in my mind 
as to the propriety of resorting to it. 



DISEASES OF THE CORNEA AND SCLERA. 223 

In this connection it may be not without interest to 
mention that I have met with two cases of monocular 
paralysis of accommodation, attended by mydriasis, 
which were clearly due to reflex dental irritation, and 
that from this same cause, as well as from the irrita- 
tion attendant upon phimosis and the existence of ad- 
hesions between the prepuce and the glans penis, I 
have observed clonic spasm of the orbicular muscle of 
the lids. 

NON-SUPPURATIVE KERATITIS. 

Interstitial Keratitis (Parenchymatous Kerati- 
tis). — This interesting variety of corneal inflammation, 
the true nature of which was first recognized by that 
admirable clinical observer, Mr. Jonathan Hutchinson, 
of London, occurs only as a result of inherited syphilis. 
Other sorts of deep keratitis may resemble it in ap- 
pearance; but they are not greatly like it in this respect, 
and are entirely unlike it in all other respects. In 
typical cases the appearance of the cornea — the so- 
called " ground-glass cornea" — is so characteristic that 
an error in diagnosis is scarcely possible. (Plate V, Fig. 
2.) On the other hand, in less severe cases it is not 
always an easy matter to recognize its true character. 

Although occasionally encountered in adults, this 
type of keratitis is essentially a disease of childhood, 
and commonly occurs between the ages of five and 
fifteen. Usually, but not always, it affects both eyes, 
generally manifesting itself first in one eye and sub- 
sequently, after days or weeks, attacking the other. 
It is seldom attended by pain, but is commonly ac- 
companied by pronounced photophobia and lacrima- 
tion, and at times by almost uncontrollable blepharo- 
spasm. Depending upon the extent and density of 



224 PREVALENT DISEASES OF THE EYE. 

the corneal opacity, vision may be but slightly affected, 
or may be reduced to mere light perception. 

Interstitial keratitis is a disease of the substantia 
propria of the cornea, more especially of its deeper 
layers, and it is attended not only by dense inflam- 
matory infiltration but by the formation of numerous 
fine blood-vessels, these vessels also being deeply seated, 
and not upon the surface of the cornea as we find them 
in p annus (Fig. 93). This feature, of new-vessel forma- 
tion, varies greatly in different cases, being at times very 
pronounced and again scarcely perceptible or, it may 
be, entirely absent. When it is marked, it gives to the 
cornea a salmon-pink or even a crimson color. There 
is also injection of the conjunctival vessels, this in- 
jection being especially noticeable near the border of 
the cornea and particularly at points where the kera- 
titis is pronounced. 

The inflammatory infiltration may begin at the mar- 
gin of the cornea or near its center. In the former case 
there is usually an ill-defined, deep-seated, nebulous 
opacity, which at a later stage may assume a salmon- 
pink appearance from the formation of new blood-ves- 
sels, as has just been mentioned. Often there are sev- 
eral such areas of infiltration, and through their exten- 
sion and confluence the whole cornea may become 
involved. When the inflammation begins centrally, 
the opacity may be of the same diffused and ill-defined 
character, or there may be many small, densely opaque, 
deeply-seated maculae. The epithelium over the areas 
of infiltration loses its luster, and the surface of the 
cornea presents an appearance like that produced by 
breathing upon cold glass. The "ground-glass" effect 
is exhibited most strikingly in those cases in which the 
infiltration is dense and the formation of new vessels is 



DISEASES OF THE CORNEA AND SCLERA. 



225 



slight. There is no tendency to tissue necrosis, and 
never any loss of corneal substance through ulceration 
or suppuration. 

The most marked characteristic of the disease is its 




r r 

Fig. 93. — Cross-section of cornea in interstitial keratitis (after a pre- 
paration of Dr. Nordenson) (Fuchs). The stroma, S, of the cornea shows 
an infiltration, which begins in the middle layer, and keeps on increasing 
more and more posteriorly, so that the deepest layers, i, have assumed the 
aspect of a granulating tissue. On account of the inequality in the degree 
of thickening of these layers, Descemet's membrane, D, is undulated; upon 
its endothelium there are deposited in places small accumulations of round- 
cells, r. In the middle and deep layers of the cornea we see the transverse 
and longitudinal section of newly formed blood-vessels, g, g, while the 
most anterior layers, and also Bowman's membrane, B, and the epithelium, 
E, are normal. 

chronicity, the tedious course which it always runs — a 
course not of weeks, but of many months. Because of 
this, it is especially important that its true character 
should be recognized at the outset, in order that those 

15 



226 PREVALENT DISEASES OF THE EYE. 

who are interested in the welfare of the patient may 
know what is in store for them. Although the sight for a 
considerable time may be seriously impaired, reduced, it 
may be, to mere light perception, as has been stated, 
the ultimate prognosis is decidedly favorable. This is 
due to the remarkable manner in which the opacity of 
the cornea slowly, but in most instances almost com- 
pletely, disappears. In no other variety of keratitis do 
we find so remarkable a change in this regard. How- 
ever, in the bad cases, in which the corneal opacity 
renders inspection of the deeper structures of the eye 
and even of the iris impossible, it is well that the progno- 
sis should be guarded, as under such circumstances 
iritis or choroido-retinitis may occur, without our 
being aware of it, and do serious damage to vision. In 
some instances, too, marked and permanent impairment 
of sight may result from persistence of the corneal 
opacity. 

The occurrence of iritis is especially to be deplored 
because, owing to the condition of the cornea, atropin 
is very imperfectly absorbed, and it is often impossible to 
induce the pupil to dilate. Even when iritis is not pres- 
ent the pupil frequently remains contracted for weeks 
in spite of the daily application of a strong solution of 
atropin, and finally responds to its influence only when 
the keratitis has measurably subsided. The occurrence 
of pain, which, as has been remarked, is not a usual 
symptom of this type of corneal inflammation, points to 
the probable development of iritis. 

Contrary to the opinion expressed by some excellent 
authorities, recurrent attacks of interstitial keratitis 
are by no means rare. Not very infrequently, after an 
intermission of months or even of years, I have seen 
the disease recur, although the inflammation is apt to 
be less severe than in the primary attack. 



DISEASES OF THE CORNEA AND SCLERA. 227 

As might be supposed, other evidences of the consti- 
tutional taint are often associated with the eye affection. 
The notched and pegged teeth — the Hutchinson teeth 
(Fig. 94) — and the physiognomy characteristic of in- 
herited syphilis — the sunken nose-bridge, the prominent 
forehead, and the fissured mouth-angles — are those most 
frequently observed (Fig. 95), while periostitis of the 
long bones and pronounced labyrinthine deafness are 




Fig. 94. — Hutchinson's teeth (Hutchinson): 1, The central upper 
incisors of a lad, aged fifteen years, the subject of inherited syphilis. The 
teeth are short, convergent, narrow from side to side at their edges, and 
show in each a vertical notch. 2, These teeth present similar characters. 
The notches, however, are less deep, while the narrowing from side to side 
is very marked. 3, The upper incisors of a girl aged seventeen years. 
There is a wide space between the central ones, and both these teeth, 
although of nearly normal length, are narrow, and show deep vertical notches. 
As is usual, the lateral incisors are more nearly normal in size and form. 
These teeth are not so typical as those shown in 1 and 2. 

not uncommon. It goes without saying, therefore, that 
in every case of supposed interstitial keratitis such signs 
of inherited lues should be searched for, and the 
family history should be inquired into. 

Treatment. — Although it is not possible by any ther- 
apeutic measures to cut short an attack of interstitial 
keratitis, there can be no question as to the value of 
treatment, when instituted early and persisted in system- 
atically. Besides lessening the discomfort of the patient 



228 



PREVALENT DISEASES OF THE EYE. 



— the photophobia, lacrimation, and blepharospasm — it 
unquestionably shortens the duration of the disease; 
not infrequently prevents the second eye from becoming 
involved; renders less probable the extension of the 
inflammation to the iris and deeper tunics of the eye, and 
greatly diminishes the likelihood of the sight being per- 
manently impaired through the persistence of the cor- 







Fig. 95. — Physiognomy characteristic of inherited syphilis (de Schweinitz). 



neal opacity. Furthermore, it improves the general 
health of the patient, and thus, perhaps, prevents the 
occurrence of other luetic lesions. 

Locally, the treatment consists in the liberal use of 
atropin, the intermittent application of hot fomenta- 
tions, and the wearing of smoke-tinted glasses. The 
application of mercurial ointment to the forehead and 



DISEASES OF THE CORNEA AND SCLERA. 229 

temples is another measure which at times is useful. 
Owing to the difficulty commonly experienced in dilat- 
ing the pupil, and the importance, if possible, of accom- 
plishing this, the atropin — which in this affection is well 
borne, even by young children — should be used in 
strong solution, usually four grains to the ounce. The 
hot fomentations are indicated especially during the 
earlier and more acute stage of the disease, and seem to 
afford the patient measurable relief. A convenient way 
of applying heat is by means of a soft, bird's-nest-shaped 
sponge, which should be dipped frequently into hot 
water, wrung out, and applied to the lids. This should 
be done, for fifteen minutes at a time, three or four times 
a day. During this stage, too, the atropin should be 
used as often as three, or even four, times in twenty-four 
hours. Later on, when the ciliary irritation and pho- 
tophobia have subsided, and mydriasis has been estab- 
lished, it need not be used oftener than twice daily, 
and the hot fomentations may be discontinued. 
Bandaging the eyes is detrimental, and should not 
be practised. The yellow oxid of mercury ointment, 
so useful in phlyctenular keratoconjunctivitis, con- 
trary to what might be expected is of no value in 
this affection. It is, indeed, recommended by some 
authorities; but, in my judgment, it does more harm 
than good, for it irritates the eye and increases the 
discomfort of the patient. Dionin has been used, and 
it is claimed with good effect; but it seems hardly likely 
that it will prove of much value in so chronic an affec- 
tion as interstitial keratitis. 

Mercury, in easily borne doses, potassium iodid, and 
iron are the constitutional remedies to be relied upon, 
and with me it is a common practice to administer the 
three in combination. Inunctions of mercurial oint- 



23O PREVALENT DISEASES OF THE EYE. 

ment are recommended, and doubtless are valuable, 
though it has been my habit to employ them only in 
very young children or when the digestive apparatus 
is disordered. 

I have found it convenient to administer mercury in 
the form of the biniodid, giving it in doses of ^ to -^ 
of a grain, according to the age of the patient, and 
always prescribing it in solution with the addition of 
potassium iodid, either just enough of the latter to 
render the mercury soluble or in such quantity as to 
make the dose from one to five grains. The syrup of 
the iodid of iron often is added to this solution, or is 
given alone or in combination with potassium iodid. 
When the iodids are not well borne, or when they have 
been given for a considerable time, the bichlorid of 
mercury is substituted, and with this the tincture of 
chlorid of iron is frequently combined. Two favorite 
prescriptions with me are the following: 

R. Hydrarg. biniodid gr. i. 

Potas. iodid gr. v. 

Syr. ferri iodid 5ss. 

Aquae 5 iiiss. 

R . Hydrarg. bichlorid gr. i. 

Tinct. ferri chlorid 5 ss. 

Aquae 5 iiiss. 

The dose of each is a teaspoonful, well diluted with 
water, three times a day, after meals. 

As fresh air and sunlight are beneficial to the patient's 
general condition, and do the eyes no harm, he should 
not be housed or kept in the dark; but, in spite of his 
photophobia, should be encouraged to go into the open 
air and take plenty of out-of-door exercise. His diet 
should be regulated in accordance with common-sense 



DISEASES OF THE CORNEA AND SCLERA. 23 I 

rules, and condiments, such as pepper, mustard, and 
the like, especially should be interdicted. The near 
use of the eyes, as in reading, writing, and sewing, is 
impracticable during the active stage of the disease, and 
should be prohibited throughout the long period of 
convalescence. 

The absorption of the corneal opacity is necessarily 
a slow process, and as this is true especially of that part 
of it which is situated in the center of the cornea and 
overlies the pupil, the improvement in vision is distress- 
ingly slow. Systematic massage of the eyes — rubbing 
the cornea gently through the lids with the finger-tip — 
which can be done best by the patient himself, but 
should not be practised until all symptoms of irritation 
have subsided, probably hastens somewhat the clearing 
process. 

Not infrequently after an attack of interstitial keratitis 
it will be found that the long-continued inflammation 
has produced a considerable amount of corneal astig- 
matism, and if this is not wholly irregular, as, unfortu- 
nately, too often is the case, glasses may be prescribed 
with great advantage. 

Pannitic Keratitis or Pannus. — In treating of 
trachomatous conjunctivitis we have already spoken 
of this variety of corneal inflammation. As there 
stated, it is a usual accompaniment of "granular 
lids," and is largely the result of the mechanical irrita- 
tion of the cornea by the roughened palpebral con- 
junctiva. Because of the greater friction exerted upon 
the cornea by the upper lid, pannus is always more 
pronounced upon, and is frequently confined to, the 
upper half of the cornea. Although in the beginning 
only the epithelium of the cornea is affected, a loss of 
luster and a slight roughening being observed, the super- 



232 PREVALENT DISEASES OF THE EYE. 

ficial layers of the substantia propria in time areinvolved. 
This happens often in consequence of the formation of 
ulcers or abscesses, which usually are the result of 
secondary infections, the condition of the cornea, 
denuded of its epithelium, being such as to favor 
bacterial invasion. 

The corneal opacity in this affection is less uniform 
and more superficial than in interstitial keratitis, and 
there is an unevenness of the surface of the cornea which 
is not present in the latter disease. A characteristic 
feature of pannitic keratitis is the formation of new 

blood-vessels upon the cor- 
nea; but these vessels, which 
^iHHfeEa grow out from the neighbor- 

m 

ing conjunctiva, are coarse 
B and superficial, and bear but 

4CUflQ little resemblance to those 

l \t . ■ which are observed in the 

keratitis of inherited syph- 
ilis (Fig;. 96). 

Fig. 96. — Trachoma with pannus 1 

(Haab). I n neglected cases the 

opacity of the cornea may be 
so great as to render the iris invisible, and to reduce sight 
to little better than light perception. While the diffuse 
opacity due to uncomplicated pannitic keratitis disap- 
pears in large measure with the subsidence of the inflam- 
mation of the conjunctiva upon which it depends, the 
opacity caused by intercurrent ulcers or abscesses, which 
is more dense in character, is apt to be indelible. Apart 
from this, however, ulcers or abscesses occurring under 
such circumstances, though they are frequently attended 
by severe pain and by an aggravation of the photo- 
phobia, lacrimation, and blepharospasm that are the 
usual accompaniments of trachomatous conjunctivitis, 



DISEASES OF THE CORNEA AND SCLERA. 233 

are not as apt to produce disastrous consequences, such 
as perforation into the anterior chamber, as are those 
which develop in a previously healthy cornea. This is 
because of the increased resisting power which the pan- 
nitic cornea derives from its abnormal vascularity. 

The diagnosis of pannus usually is not difficult. The 
coarse and superficial character of the new blood- 
vessels, the unevenness of the corneal surface, the lack 
of uniformity in the opacity and the fact that it is com- 
monly limited to the upper half of the cornea indicate 
its true nature, and should lead at once to an inspec- 
tion of the tarsal conjunctiva of the upper lid, the ap- 
pearance of which in trachoma is so typical as to place 
the diagnosis beyond doubt. 

Treatment. — The treatment of pannus is the treatment 
of trachoma, and this has been fully considered already. 
It may be well, however, to say that the employment of 
atropin, and in strong solution, is especially indicated 
when intercurrent ulcers or abscesses occur, and that 
the lotion of opium, so often commended, is also very 
useful under the same circumstances; and, further, 
to mention the decided benefit that results in some 
obstinate cases of pannus, which do not respond to the 
usual remedies, from the performance of the simple 
operation of canthotomy. 

This operation, which can be done by any one who 
has a modicum of surgical skill, does good by lessening 
the tension of the upper lid, and so reducing the friction 
which it exerts upon the cornea. It consists in a length- 
ening of the palpebral aperture and a division of that 
part of the external canthal ligament which is attached 
to the tarsal cartilage of the upper lid. It is performed 
as follows: With a pair of straight scissors the external 
canthus, at one cut, is divided horizontally outward for 



234 PREVALENT DISEASES OF THE EYE. 

a distance of 8 or io mm. (Fig. 97). The upper lid is then 
put upon the stretch, and the superior half of the external 
canthal ligament, which is thus made tense, is cut through 
with the scissors, the points of which are inserted vertic- 
ally beneath the upper lip of the skin wound. The first 
incision will have divided both skin and conjunctiva, 
and the final step of the operation consists in attaching 
the edges of the conjunctival wound to those of the skin 
wound by several fine sutures, so that the cut edges of 
the skin shall not unite one with the other (Fig. 98). 




Fig. 97. — Canthotomy. The incision (modified after Czermak). 

For this purpose I employ fine black silk and half-curved 
needles, introducing four sutures, two to bring together 
the upper and two the lower lips of the wound. It is 
well to make the horizontal incision rather longer than 
would seem to be necessary, since during the healing 
process it is sure to shorten somewhat. The sutures 
may be removed after three or four days. Before, and 
for a time after, their removal the outer canthus should 
be anointed with borated vaselin or cold-cream, and 
any tendency to grow together which the edges of the 



DISEASES OF THE CORNEA AND SCLERA. 235 

skin wound may show should be overcome by gently 
stretching them apart. No deformity is left by the 
operation; indeed, when the palpebral aperture is preter- 
naturally small, as is sometimes the case in old 
trachoma, a distinct improvement in the appearance 
of the eye results. 

Opacities of the Cornea. — All varieties of ker- 
atitis, as has been stated, are attended by more or less 
pronounced impairment of the transparency of the 




Fig. 98. — Canthotomy. The stitches ready to be tied (Haab). 

cornea. Often this loss of transparency is evanescent, 
but not infrequently, especially when consequent upon 
suppurative keratitis, it is permanent. Permanent 
corneal opacities may be caused also by interstitial, and 
other forms of deep, keratitis, by wounds of the cornea, 
by severe iritis, and by protracted disease of the deeper 
tunics of the eye; while one common form of opacity, 
the well-known arcus senilis — due to colloid degenera- 
tion of the superficial layers of the cornea — occurs 
spontaneously, and, it may be remarked, is frequently 



236 



PREVALENT DISEASES OF THE EYE. 



observed, contrary to what its name would seem to in- 
dicate, in persons who are much too young to be desig- 
nated as ''senile." Apart from the trivial unsightli- 
ness which attends it, this last-mentioned variety of 
corneal opacity causes no inconvenience, and does not, 
as was once supposed, interfere in any degree with the 
success of operations, such as extraction of cataract, 
that involve section of the corneal limbus. Undoubt- 
edly, the largest number of indelible opacities of the 
cornea are the result of ulcers, the density of the opacity 
being dependent in great measure upon the extent to 




Fig. 99. — Leucoma resulting from a lime burn (Lawson). 

which the substantia propria has been destroyed by the 
ulcerative process. 

According to their density, corneal opacities are desig- 
nated as nebulce, macula, or leucomata (Fig. 99), and 
when, in consequence of an ulcer which has perforated 
into the anterior chamber, the iris is attached to the 
corneal scar, we have a leucoma adherens or a leucoma 
with anterior synechia (Fig. 100). 

Marked corneal opacities are always disfiguring; but 
whether they cause impairment of sight or not depends 
less upon their density than upon their location, and 
upon whether they are attended by considerable distor- 
tion of the curvature of the cornea. Thus, a very slight 
nebulous opacity, scarcely perceptible by simple inspec- 
tion, if situated in the center of the cornea, in the line of 



DISEASES OF THE CORNEA AND SCLERA. 237 

vision, may seriously impair the sight; whereas even a 
large and dense leueoma at the margin of the cornea 
may cause no visual disturbance whatever. The im- 
pairment of sight caused by such faint, central nebulae, 
it is true, is due less to the slight opacity than to the 
marked irregular astigmatism which is frequently present 
under such circumstances, and which leads to the 
formation of distorted and imperfect retinal images. 
In the same way corneal scars, which are not in the 
direct line of vision, may give rise to great disturbance 




Fig. 100. — Leueoma with anterior synechia. 

of sight if they are attended by alteration in the curva- 
ture of the cornea. 

A superficial, milk-white opacity of the cornea results 
at times from the injudicious use of collyria containing 
lead acetate. This happens only when there is denuda- 
tion of the cornea from ulceration or traumatism, and 
is caused by the deposit of an insoluble salt of lead 
upon the denuded surface. Because of its density, 
such an opacity, if central, produces marked disturb- 
ance of vision. To avoid the risk of such an accident, 
solutions of "sugar of lead" should never be applied 



238 PREVALENT DISEASES OF THE EYE. 

to the eye when from any cause loss of corneal tissue 
has taken place. 

There is little excuse for confounding corneal opacities 
with opacities situated in the crystalline lens, and yet, 
with those unfamiliar with diseases of the eye, this is 
an error of not very infrequent occurrence. If by 
simple daylight inspection the location of the opacity is 
not evident, it can be determined, beyond doubt, by the 
aid of oblique illumination, which, therefore, should 
always be employed under such circumstances. 

Treatment. — Little can be done to promote the ab- 
sorption of corneal opacities of longstanding. Nature, 
as has been indicated, often accomplishes a great deal, 
especially when the opacity is the result of inflammatory 
infiltration unattended by necrosis of true corneal tissue. 
Massage, — rubbing the cornea through the upper lid 
with the finger-tip, — if employed perseveringly, may 
do some good, provided the opacity is not too dense and 
is not of too long standing. In connection with massage 
an ointment of yellow oxid of mercury (gr. j to vaselin 
5j) may be used. Subconjunctival injections of salt 
solution (one per cent, to five per cent.) are not without 
value in suitable cases, that is to say, in opacities of 
not too long duration, and, under such circumstances, 
dionin (in five per cent, solution), which acts in 
much the same way as the salt injections do — by stim- 
ulating the lymph currents of the eye — is of undoubted 
value. The chances of improvement are better in 
children than in adults. 

When the opacity overlies the pupil, but more espe- 
cially when the sight of both eyes is impaired, consider- 
able improvement in vision may be obtained by an 
iridectomy, the artificial pupil being placed behind a 
clear or relatively clear portion of the cornea. Con- 



DISEASES OF THE CORNEA AND SCLERA. 239 

spicuous leucomata are sometimes tattooed with India 
ink, in order to render them less unsightly. 

Staphyloma of the Cornea (Anterior Staphy- 
loma). — Occasionally as a result of a penetratingwound 
or of extensive and deep ulceration of the cornea, 
but usually in consequence of more or less complete 
corneal necrosis occurring during the course of a puru- 
lent (gonorrheal) conjunctivitis, an irregular protrusion 
of the anterior segment of the eyeball occurs. When this 
protrusion is confined to a limited area of the cornea, 
as is more apt to be the case when it arises from one of 
the two first-mentioned causes, it is known as partial 
staphyloma; when it involves the whole cornea, or, as 
sometimes happens, the anterior portion of the sclera 
as well, it is known as total staphyloma. 

In total staphyloma the protrusion, which may be 
inconsiderable or so great that the lids cannot be closed 
over it, is irregularly globular in shape and occasionally 
somewhat lobulated, is bluish-white in color, and 
frequently exhibits upon its surface several coarse, 
tortuous veins (Plate VI, Fig. i). The protuberant tissue 
consists mainly of the iris reinforced by newly formed 
connective tissue, some remnants of the cornea, perhaps, 
being found incorporated with its base (Fig. 101). The 
development of the staphyloma is due to the inability 
of this improvised tunic to resist the pressure exerted 
by the intraocular fluids. In partial staphyloma the 
walls of the ectasia are made up of corneal, iridic 
and newly formed scar tissue, and the protuberance 
is commonly near the margin of the cornea. When 
the whole cornea is involved in the staphylomatous 
process vision is necessarily reduced to mere perception 
of light; but when the defect is partial, good vision 
may be retained, though, owing to the distortion of 



24O PREVALENT DISEASES OF THE EYE. 

the corneal curvature and the displacement of the pupil 
so often present, this is usually not the case. 

Because of its poor resisting power, the staphyloma- 
tous tissue is not infrequently the seat of recurrent attacks 
of inflammation. This happens especially in those 
cases of total staphyloma in which the protuberance is 
so great as not to receive the protection of the lids. 
In such cases, too, accidental rupture of the thinned 
walls of the staphyloma is not uncommon. Infection 




Fig. 101. — Cross-section of a total staphyloma, the result of exten- 
sive necrosis of the cornea (schematic) (Fuchs). Only the marginal por- 
tions, c, of the cornea are preserved, and these are still partially infiltrated. 
Between them bulges the iris, which is driven strongly forward and which 
consequently is thinned so that the pigment, t, upon its posterior surface 
shines through it and gives the prolapse a blackish hue. The pupil, p, 
is closed by a membrane. The space, h, between the iris and the lens 
is the enlarged posterior chamber. Of the anterior chamber only the shal- 
low, slit-like, annular space, v, is left. This no longer communicates any- 
where with the posterior chamber (seclusio pupillae). 

of the deeper tunics of the eye, leading to purulent 
panophthalmitis, is another accident which may occur 
at any time. 

Treatment. — In its incipiency the development of a 
staphyloma — of a partial staphyloma more especially — 
may be arrested, in some instances, by the continuous 
support of a not too tightly applied pressure bandage. 
At this stage, too, a partial abscission of the ectasia or 
a well-placed iridectomy may be very effective. In total 
staphyloma restoration of vision is impracticable, and 



PLATE VI. 




' 






Fig. i. — Total Staphyloma (after Sichel). 




6, iWtthd. I <L 



nor 



Fig. 2. — Episcleritis. 




5-lAeofc-crti^ 



Fig. 3. — Serous Iritis (Uveitis). 



DISEASES OF THE CORNEA AND SCLERA. 24I 

enucleation of the eye is commonly indicated, not for 
its cosmetic effect only, but because it eliminates all 
the possible complications mentioned as apt to occur. 
In children, too young to wear an artificial eye, abscis- 
sion may be practised in accordance with the method 
recommended by Knapp, the wound being closed by 
bringing together, with four or five stitches, the pre- 
viously undermined conjunctiva. 

In partial staphyloma, if the vision is good and the 
ectasia shows no tendency to increase, surgical inter- 
ference is usually contraindicated; but, on the other 
hand, if the vision is poor, and especially if the staphy- 
loma is progressing, an iridectomy may do much good, 




1 

El * / s'J?M.,r -J 

Fig. 102. — Conical cornea (de Schweinitz). 

not only by its direct effect upon vision, but by reducing 
the intraocular tension, and so staying the increase of 
the staphyloma. 

Conical Cornea (Keratoconus). — In this condi- 
tion, which is comparatively rare and therefore calls 
for but brief mention, the cornea gradually assumes, 
usually without considerable loss of transparency, a 
distinctly conoidal shape (Fig. 102). This change 
in the form of the cornea gives rise to a high grade 
of myopia, attended by excessive symmetrical aberra- 
tion of the eye, in consequence of which vision is greatly 
impaired. 

Treatment. — In the lower grades of this anomaly 
16 



242 PREVALENT DISEASES OF THE EYE. 

carefully adjusted glasses are helpful. In the higher 
grades, especially if the condition is progressing, an 
effort should be made to reduce the protrusion by 
cautiously cauterizing the apex of the cone with the 
galvanocautery, care being taken not to perforate the 
cornea. This delicate procedure, it should be remarked, 
requires for its successful performance especial skill and 
experience. 

Tumors of the cornea are exceedingly rare, and 
so do not demand our consideration. 

Traumatic lesions of the cornea, which are of 
common occurrence, are treated of in Chapter XIII, 
devoted to injuries of the eye. 

DISEASES OF THE SCLERA. 

The tough and non-vascular sclera, or sclerotic coat 
of the eye, is not often the seat of diseased processes. 
In deep keratitis the neighboring sclera is at times 
involved, the condition being known as kerato-scleritis, 
and in syphilitic irido-cyclitis (especially in the negro 
race) the anterior portion of the sclera may become 
implicated, and a staphylomatous condition may result 
from the softening and thinning which it undergoes. 

Scleritis (Sclerotitis ; Sclero-conjunctivitis) . — 
Inflammation confined to, or having its starting-point 
in, the sclera is usually of rheumatic or gouty origin. 
Two varieties of scleritis are encountered — an acute, 
diffuse inflammation, which is aptly described by the 
name sclero-conjunctivitis, and a more persistent form, 
in which the inflammation is circumscribed. 

Sclero-conjunctivitis. — In this type of scleritis the 
inflammation is often capricious and fleeting in char- 
acter, attacking one eye to-day, and after twenty-four 
or forty-eight hours disappearing from this eye only to 



DISEASES OF THE CORNEA AND SCLERA. 



243 



manifest itself in the other. It is characterized by 
marked, general injection of the conjunctival and sub- 
conjunctival vessels, and is usually attended by pro- 
nounced pain, photophobia, and lacrimation. 

In chronic scleritis (Fig. 103) the injection and in- 
flammation are confined to a limited area of the sclera, 
usually near the corneal margin, and the hyperemic 
vessels are finer and more deeply seated, in consequence 
of which the affected area presents a dusky red or pur- 
plish appearance. Pain and photophobia are less con- 
spicuous in this variety, but involvement of the cornea 
or iris is more apt to occur. 




Fig. 103. — Scleritis (Haab). 

Acute diffuse scleritis or sclero-conjunctivitis is to 
be distinguished from simple conjunctivitis by the pain 
and the greater photophobia and lacrimation which 
attend it, and by the fact that it is commonly monocular. 
Its association with other manifestations of a rheumatic 
or gouty diathesis affords additional evidence of its real 
character. Except by the course of events, it is not to 
be distinguished from the incipient stage of luetic or 
rheumatic iritis — the stage, often observed, in which, 
as yet, the iris is neither muddy nor swollen, and in 
which the pupil dilates fully and symmetrically to 
atropin. 

Treatment. — In the acute form of the disease atropin 



244 PREVALENT DISEASES OF THE EYE. 

in strong solution, and moist heat (hot water or, better 
still, the lotion of opium, applied hot) are indicated, and, 
internally, sodium salicylate in liberal doses, supple- 
mented by a brisk purgative. In the circumscribed 
form, atropin and the lotion of opium are called for, 
while potassium iodid, sodium salicylate, lithium, and 
colchicum are the constitutional remedies apt to accom- 
plish the greatest good. 

Episcleritis. — This is an affection of not un- 
common occurrence, and consists in a circumscribed 
inflammation, usually monocular, of the episcleral 
connective tissue, in which the superficial layers of the 
sclera are frequently involved (Plate VI, Fig. 2) . The in- 
flamed area, which is always adjacent to the corneal lim- 
bus, is somewhat elevated, and of a dark red or purplish 
color. Pain is not a usual symptom, but photophobia 
and an irritability of the eye, unfitting it for near work, 
are commonly present. This affection, which is rarely 
encountered in children, and is commoner in women 
than in men, does not respond satisfactorily to treat- 
ment, and, still worse, when seemingly cured, is prone 
to recur, it may be at the same spot or upon some other 
part of the pericorneal region. 

Episcleritis at times bears a close resemblance to 
phlyctenular conjunctivitis, and it might be confounded, 
also, with the bulbar variety of vernal catarrh. Its 
course, however, is more protracted than the former 
disease and much less protracted than the latter. 
Moreover, there is no tendency to ulceration, as in 
phlyctenular conjunctivitis, and no itching, as in vernal 
catarrh. 

It is often impossible to assign a cause for episcleritis; 
but there can be no doubt that in many instances it is 
dependent upon a rheumatic or gouty diathesis. 



DISEASES OF THE CORNEA AND SCLERA. 245 

Treatment. — This is much the same as in circum- 
scribed scleritis, Atropin with boracic acid, the 
strength of the solution depending upon the ciliary 
irritation and photophobia present, or holocain with 
boracic acid (holocain muriatis, gr. i; acid, boracic, 
gr. x; aq. destil., oi, to be dropped into the eye every 
three or four hours), are the most useful local remedies, 
to which may be added the lotion of opium, if there is 
pain or marked ciliary irritation. The yellow oxid of 
mercury, so efficacious in phlyctenular conjunctivitis, 
is contraindicated. Potassium iodid in moderate doses, 
and frequently in combination with syrup of the iodid 
of iron, is the constitutional remedy I have found most 
beneficial. Other useful remedies are sodium salicylate, 
and lithium, preferably in the form of the natural 
mineral water. Regulation of the diet and of the 
bowels is also important. 



CHAPTER VII. 
DISEASES OF THE IRIS AND CILIARY BODY. 

DISEASES OF THE IRIS. 

Iritis. — Iritis, or inflammation of the iris, is one of 
the common affections of the eye, and it is one with 
which it is especially important the general practi- 
tioner should be familiar. It arises from a variety of 
causes, may attack one or both eyes, and, though almost 
always amenable to treatment if recognized in its incep- 
tion and judiciously managed, it is apt to impair the 
sight more or less seriously, and permanently damage 
the integrity of the eye if allowed to run its course un- 
checked, or if improperly or only tardily treated. It is 
essential, therefore, that its true character should be 
recognized at the outset, and that the requisite thera- 
peutic measures should be resorted to without delay. 

The diagnosis of inflammation of the iris is commonly 
not a difficult matter, and the indications for its treat- 
ment are usually plain. Nevertheless, it is frequently 
confounded with other forms of inflammation of the 
eye, and for this reason improperly treated. In conse- 
quence of this, or because of the ignorance or indiffer- 
ence of those whom it attacks, it is by no means an un- 
common cause of blindness. 

The existence of iritis is to be suspected whenever, 
without increase of intraocular tension or other evident 
cause, pain in and around the eye, usually worse at 
night, is complained of, and is accompanied by peri- 
corneal subconjunctival injection and a contracted 

246 



DISEASES OF THE IRIS AND CILIARY BODY. 247 

pupil. This concourse of symptoms does not neces- 
sarily indicate the presence of iritis, but it is distinctly 
suggestive, and should lead to a careful search for other 
evidences of its existence. A dull, lack-luster appear- 
ance of the iris, with appreciable change of color and 
more or less swelling of its tissue; immobility of the 
pupil, and perhaps loss of its circular form; diminished 
transparency of the aqueous humor, and frequently of 
the cornea as well, with consequent indistinctness of 
vision; adhesions between the margin of the pupil and 
the anterior capsule of the lens, which, however, are 
frequently not evident until a mydriatic has been used; 
and in severe cases a grayish opacity of the pupil from 
the deposition of an organized exudate upon the lens 
capsule, are the other changes which should be sought 
for, and which, if found, establish the diagnosis beyond 
question. 

In examining a case of suspected iritis the use of "ob- 
lique illumination" is of great assistance, since it en- 
ables one to detect slight changes in the cornea and in 
the tissue of the iris, and in many cases to discover ad- 
hesions between the iris and lens, which can not be seen 
by simple inspection. If, however, any doubt remains 
as to the existence of iritis after this method of examina- 
tion has been employed, a weak solution of atropin (gr. 
ss.-i to Bi) or of homatropin (gr. iv to §i) or euphthal- 
min (gr. viii to 5i) should be dropped into the eye, 
when, if iritis is present, the pupil will almost certainly 
dilate in an irregular manner, showing points of ad- 
hesion between its margin and the lens capsule. 

The character of the vascular injection of the eyeball, 
while helpful, is not always an entirely trustworthy guide 
in the differential diagnosis of iritis. When, however, 
it is most marked around the corneal margin, is of a 



248 PREVALENT DISEASES OF THE EYE. 

pinkish rather than a brick-red color, and the vessels 
involved are for the most part small, and radiate more 
or less regularly from the margin of the cornea toward 
the equator of the globe, we may, at least, conclude that 
structures deeper than the conjunctiva are involved in 
the inflammatory process, and that the existence of iritis 
is probable. 

Among the causes of iritis, syphilis deserves the most 
prominent place. Traumatism is another frequent 
cause, and not only when the iris itself is involved in the 
injury, but also when the cornea, lens, or ciliary body 
is wounded. Rheumatism and gout, diabetes, and 
the acute infectious diseases also deserve mention in 
this connection, and gonorrhea, though an infrequent 
cause, occasionally gives riseto it, the ocular inflammation 
having the same relation to the urethral disease that 
gonorrheal arthritis has. Iritis may also be a conse- 
quence of inflammation of other structures of the eye, 
as, for instance, abscess or perforating ulcer of the 
cornea. 

There is also another cause of iritis to which I am 
disposed to attach importance, and which I believe to 
be an essential factor in the production of several appar- 
ently distinct varieties of the disease. I refer to an 
influence transmitted through sympathetic or "trophic" 
nerves, which is frequently reflex in character, and is 
probably dependent upon structural changes in gray 
nerve matter, either in the cerebral ganglia themselves, 
or in the ganglia connected with the fifth nerve, or in 
both. It is such an influence as this, I believe, that 
determines the development of sympathetic iritis, the 
iritis which is frequently found associated with herpes 
zoster ophthalmicus, that which occasionally follows 
malarial attacks, and probably also certain cases of 



DISEASES OF THE IRIS AND CILIARY BODY. 



249 



serous iritis. In this category belong also those cases 
of iritis which rightfully, I think, have been ascribed to 
reflex dental and reflex uterine irritation, as well as 
certain intractable forms of irido-keratitis, that not 
infrequently are accompanied by anesthesia of the cor- 




Fig. 104. — Vertical section, showing total posterior synechia (Fuchs). 
The iris is adherent by its posterior surface to the anterior capsule of the 
lens and also to the anterior surface of the ciliary body. The posterior 
chamber consequently is obliterated and the anterior chamber deepened 
at its periphery, b; at this spot the iris is strongly retracted and at the same 
time is here the most thinned through atrophy. The exudate connecting the 
iris with the lens also stretches as a thin membrane, p, across the pupil. 
The exudate, s, springing from the ciliary body, envelops the pos- 
terior surface of the lens and by its shrinking draws the ciliary processes- 
toward the center. As a result of this a separation of the ciliary body, 
c, from its bed has already taken place below, and in the intermediate space 
are seen the disjoined lamellae of the suprachoroid membrane, a. The 
pigment epithelium, /, of the ciliary processes has undergone proliferation. 
At the lower part of the cornea there is a zonular opacity, g. The lens is 
swollen and is opaque throughout; there is no hard undisintegrated nu- 
cleus (*. e., it is a soft cataract). 



nea. Obstinacy and intractability are the common 
characteristics of these several varieties of iritis, and in 
the pathological changes which they exhibit, especially 
the tendency of the entire posterior surface of the iris 
to become glued to the lens capsule (Fig. 104), a condi- 
tion seldom met with even in the worst cases, for 



25O PREVALENT DISEASES OF THE EYE. 

example, of syphilitic iritis, there are also striking re- 
semblances.* 

The consequences of a severe attack of iritis which 
has been neglected or has been improperly treated are 
disastrous to the integrity of the eve in several ways. 
In the first place, especially in syphilitic iritis, other 
structures of the eve, for example, the ciliary body, 
choroid, retina, and lens, are liable to become involved 
in the inflammatory process, and may suffer irreparable 
damage (Fig. 105). Again, the pupil may be closed 
or obstructed by an organized membrane ('occlusion), 
so that vision is reduced to mere perception of light; or 
the iris may become adherent to the anterior surface 
of the lens, at its pupillary margin only (exclusion), or 
throughout its whole extent 'complete posterior 
synechia) (Fig. 104). In the two former conditions 
operative interference may accomplish great good; in 
the latter, whatever plan of treatment is adopted, the 
prognosis is much less favorable, and in time the deeper 
tunics are apt to suffer and the lens to lose its trans- 
parency. Sympathetic inflammation of the fellow-eve 
is another result of neglected iritis, which, though 
not of frequent occurrence, happens often enough to 
deserve mention. 

Although there are so many causes of iritis, there are, 
strictly speaking, but three different kinds of iritis 
— plastic iritis, purulent iritis, and serous iritis (Descem- 
etitis, uveitis). The first named variety, plastic iritis, 
characterized bv the formation of an exudate, rich in 



* The author realizes that to express such an opinion as this re- 
garding the genesis of inflammation is to run counter to the teachings 
of modern pathology; but he is not convinced that the last word 
has vet been spoken upon this subject. (Compare foot-note on page 
259-') 



DISEASES OF THE IRIS AND CILIARY BODY. 



2^1 



cells, which tends to become organized, is by far the 
most comprehensive. It includes most cases of syphil- 




Fig. 105. — Meridional section through ciliary region, including the 
iris and part of the cornea and lens (Fuchs) : C, Cornea ; pe, pc, pigmented 
and non-pigmented cells of the pars ciliaris retinae; L, lens; M, ciliary 
muscle; r, its radiating, Mu, its circular fibers; ci, anterior ciliary artery; 
s, canal of Schlemm; c, /, anterior surface of iris; break at cr; sp, 
sphincter pupillae; p, edge of pupil; P, ciliary process; h, pigment lining 
iris, partly separated at v; a, blood-vessel; z v z v fibers of suspensory liga- 
ment, enclosing spaces i, i; k, lens-capsule; /, ligamentum pectinatum. 



itic, of rheumatic and gouty, of gonorrheal, and of 
sympathetic iritis. Many cases of traumatic iritis are 



252 PREVALENT DISEASES OF THE EYE. 

also of this character, and so are most of those which 
have been spoken of as due to "trophic" nerve in- 
fluence. 

Purulent iritis is less common. It is usually the re- 
sult of penetrating wounds of the eyeball, or of opera- 
tions in which the globe is opened, and is almost always 
due to the presence of a pyogenic micro-organism. It 
may also follow severe suppurative inflammation of 
the cornea. 

Serous iritis or, more correctly, uveitis, is a disease 
by no means of rare occurrence, yet it is one about the 
pathology of which we have much to learn. There is* 
no doubt but that the iritis is usually only a part of 
an inflammatory process which involves the entire 
uveal coat. In some instances it seems to be de- 
pendent upon a rheumatic diathesis, and in others, 
as has already been intimated, upon a reflex or "trophic " 
nerve influence, while, oftener than not, it is impossible 
to assign a cause for it. The distinguishing characteris- 
tics of serous iritis (Plate VI, Fig. 3), which, fortunately, 
is rarely a binocular affection, are that the pupil is not 
contracted, as in other forms of inflammation of the 
iris; that posterior synechiae rarely occur; that there is 
a disposition to increased intraocular tension; that the 
vitreous humor is often diffusely clouded or contains 
numerous floating opacities; and, most typical of all, 
that there is commonly a deposit of minute opaque dots, 
of a yellowish-gray color, upon the inner surface of the 
cornea. These dots, which are due to the deposition 
of round cells and coagulated fibrin upon the corneal 
endothelium (Fig. 106), are usually arranged in a 
triangular shape, the base of the triangle being at the 
lower margin of the cornea, while its apex reaches up to, 
or may even extend beyond, the center of the cornea. 



DISEASES OF THE IRIS AND CILIARY BODY. 



253 



Occasionally the affection exhibits a mixed type, and the 
characteristic dots upon the corneal endothelium, etc., 
are attended by a disposition to the formation of pos- 
terior synechia?. It usually runs a protracted course, 
and responds far from satisfactorily to treatment. 
Unless the tension assumes a glaucomatous character, 
pain is not often complained of, and there is an absence 
of pronounced photophobia. Owing to the opacity of 
the vitreous humor and the condition of the cornea, 




Fig. 106. — Section showing deposit of round cells and coagulated 
fibrin upon the inner surface of the cornea in uveitis. Magnified 140 X 1 
(Fuchs). The posterior surface of the cornea, C, is covered by Descemet's 
membrane, D, and the endothelium, e. The latter, which as a whole is 
of normal character, is wanting at the spot where the deposit, P, is situated. 
This deposit consists of an accumulation of cells with interspersed pigment 
granules which are partly free and partly inclosed in the round cells. In 
the place where no deposits are situated the posterior surface of the cornea 
is covered by a layer of exudation consisting of two strata, an anterior one, 
b, composed of round cells, and a posterior one, /, formed of coagulated 
fibrin. 

vision during the height of the attack may be reduced to 
little better than light perception. Serious and per- 
manent impairment of sight may result, if the increase 
of intraocular tension has been persistent and pro- 
nounced enough to injure the optic nerve, or if, as 
not infrequently happens, the retina has suffered in 
consequence of the general uveitis. 

All varieties of plastic iritis (Plate VII, Fig. 1), as has 
been stated, are characterized by a tendency to the for- 



254 



PREVALENT DISEASES OF THE EYE. 



mation of an organized exudate, but this tendency is much 
more marked in some than in others. It is especially 
so in sympathetic iritis, in the iritis of herpes zoster 
ophthalmicus, and, in fact, in all those forms of iritis 
which appear to be due to " trophic" ' nerve influence. 
In syphilitic and in rheumatic iritis this tendency usu- 
ally manifests itself by the formation of adhesions 
between only the pupillary margin of the iris and the 
capsule of the lens (Fig. 107) ; but in sympathetic 




Fig. 107. — Annular posterior synechia, with occlusion of pupil and i 
bombe (Deaver). 



ins 



and other allied forms of iritis a felt-like exudation 
forms upon the posterior surface of the iris, causing it 
to adhere throughout its whole extent to the lens, and 
the pupil is commonly occluded by similar material 
(see Fig. 104). Under such circumstances, too, project- 
ing portions of the anterior surface of the iris may be- 
come adherent (without ulceration) to the inner sur- 
face of the cornea, giving rise to anterior synechiae. 

Syphilitic iritis, which is usually attended by severe 
pain, and by marked photophobia and lacrimation, 



PLATE VII. 




5 -"fteot, 



id 



/10J,~ 



t 



Fig. i. — Plastic Iritis. Pupil partly dilated by atropin, showing two 
posterior synechise. 




0-. 






Fig. 2. —Inflammatory Glaucoma. 



DISEASES OF THE IRIS AND CILIARY BODY. 255 

commonly manifests itself during the secondary stage of 
the disease, in association with the macular eruption 
and the appearance of condylomatous growths. Less 
frequently it occurs in the tertiary stage. It is also 
met with in inherited syphilis, sometimes in infancy, 
sometimes even as a prenatal affection, but oftenest 
between the ages of seven and fifteen years, in connec- 
tion with an outbreak of interstitial keratitis. About 
fifty per cent, of all cases of iritis are due to syphilis, 
inherited or acquired. 

A pathognomonic, but by no means constant, feature 
of syphilitic iritis is the development upon the anterior 
surface of the iris of yellowish or reddish-brown nod- 
ules, which project forward into the anterior chamber, 
and sometimes even press against the cornea. Usually 
there are not more than one or two present; but they 
may be so numerous, and of such size, as to fill the an- 
terior chamber. They occur more frequently in the 
iritis which develops during the secondary stage of the 
disease, and are then of the nature of condylomata 
(Fig. 108); those met within the iritis of tertiary syphilis 
are gummatous in character. Hence the former variety 
of iritis is sometimes designated iritis condylomatosa, and 
the latter variety, iritis gummosa. They may undergo 
absorption, or may disappear through fatty or puru- 
lent degeneration. The inflammation of the iris tissue 
being more intense over the area which corresponds to 
their base, we find here a special tendency to the forma- 
tion of adhesions to the lens capsule. All the varieties 
of iritis may be complicated by "hypopyon," though it is 
more common in the purulent and syphilitic types. 
It is due to the deposition from the aqueous humor of 
leukocytes or of round cells and fibrin, and, as a rule, 
undergoes absorption slowly. As the deposit may or 



256 



PREVALENT DISEASES OF THE EYE. 



may not consist of leukocytes the term, as commonly 
employed, is inexact. 

Sympathetic Iritis. — Although exceptionally sym- 
pathetic ophthalmitis manifests itself as a neuro- 
retinitis or choroido-retinitis, it very generally begins 
as an iritis or an irido-cyclitis, and, even in the rare 
instances in which the inflammation commences at the 
posterior pole of the eye, it soon extends to the iris and 
ciliary body unless promptly brought under control. 




Fig. 108. — Syphilitic iritis, showing condyloma. Pupil dilated by atro- 

pin (Ffaab). 



It is not inappropriate, therefore, to consider this affec- 
tion in connection with other forms of iritis. 

There are but few diseases of the eye in which the 
prognosis is more grave, and in which treatment is of 
less avail, than in sympathetic ophthalmitis. It is usu- 
ally the result of a severe traumatic lesion, commonly 
of a penetrating wound, of the primarily affected or 
"exciting eye." Wounds involving the iris and ciliary 
body, and those complicated by the lodgment of a 



DISEASES OF THE IRIS AND CILIARY BODY. 257 

foreign bodv in the interior of the eye, are especially 
apt to give rise to it. It may also be induced by severe 
and protracted inflammation of the iris, ciliary body, 
and choroid of non-traumatic origin. It is interesting 
to note that a sympathetic inflammation leading to com- 
plete destruction of sight may be brought about by an 
injured or diseased eye which still retains a useful 
amount of vision. Another point of interest is that 
the disease has no definite period of "incubation," if 
we may use the expression, that the interval between 
the receipt of the injury or the occurrence of the inflam- 
mation in the exciting eye and the development of the 
sympathetic affection in the fellow-eye may vary from 
two or three weeks to very many years. 

Usually, but not always, the outbreak of an attack of 
sympathetic inflammation is preceded by a period, 
which may be brief or very prolonged, of sympathetic 
irritation in the sympathizing eye. This condition, 
which is unattended by structural changes, and, there- 
fore, is to be sharply differentiated from sympathetic 
ophthalmitis, is characterized by the existence of pho- 
tophobia and lacrimation and by a "weakness" or 
irritability of the eye, which renders it incapable of 
near work, especially. Diminution of accommodative 
power and a tendency, upon slight provocation, to 
hyperemia of the conjunctival vessels are also frequently 
present. All these symptoms, constituting sympathetic 
irritation, it should be remarked, disappear promptly 
upon the removal of the exciting cause, that is to say, 
upon the enucleation of the primarily affected eye. 

Unlike sympathetic irritation, sympathetic inflamma- 
tion, when once established, though it may be favorably 
influenced, is seldom cut short by the removal of the 
exciting eye. On the contrary, though detected in its 

*7 • 



258 PREVALENT DISEASES OF THE EYE. 

incipiency and combated by every known therapeutic 
means, it commonly leads, after a prolonged course 
attended by much suffering, to complete destruction 
of sight and ultimately to atrophy of the eyeball. The 
inflammation is usually of a plastic character, and when 
it involves the iris gives rise, as has been mentioned 
already, to the formation of a felt-like exudate, which 
occludes the pupil, and glues the entire posterior surface 
of the iris to the lens capsule (see Fig. 104). The 
choroid and retina are soon implicated, and in this way 
light perception is lost. 

As to the manner in which the inflammation is 
lighted up in the sympathizing eye, and as to the role 
played by the exciting eye in the process, there is still 
much uncertainty and great difference of opinion. The 
soundness of the more prevalent view that the inflamma- 
tion in the second eye is caused by micro-organisms 
which have migrated to it from the primarily affected 
eye, probably along the lymph-channels of the optic 
nerves, has certainly yet to be demonstrated; and, it 
may be observed, there are many features in the clinical 
history of the disease that militate against this view. 
On the other hand, there is, it seems to me, much evi- 
dence to support the older theory that sympathetic 
ophthalmitis is a neuropathic affection; that the inflam- 
matory changes in the sympathizing eye are the product 
of a reflex influence which is provoked by the intense 
and continued irritation of the ciliary nerves in the 
primarily affected eye, and that the peculiar character- 
istics of this inflammation — its intractability and its 
malignancy — are the result solely of this reflex influence, 
and not of especially virulent bacterial action. It is 
in accordance with this view that I have spoken of 
sympathetic iritis as belonging to the group of "trophic" 



DISEASES OF THE IRIS AND CILIARY BODY. 259 

nerve inflammations of the eye, along with herpes 
zoster ophthalmicus, reflex dental, and postmalarial 
iritis and keratitis, etc. 

As I long ago pointed out,* it is probable that the 
inflammatory manifestations in the sympathizing eye 
are preceded by, and are dependent upon, pathological 
changes in the ganglia connected with the fifth nerve 
and in the brain-centers which have to do with the 
metabolism of the eye. These changes, it seems prob- 
able, are not unlike those which occur in the gasserian 
ganglion and in the ganglia upon the posterior roots of 
the spinal nerves in herpes zoster. f In this connection 
it is interesting to note the close resemblance which 
the iritis of herpes zoster ophthalmicus bears to that 
which we meet with in sympathetic ophthalmitis. Like 
the latter, it is obstinate and intractable, and in each 
the iris shows the same tendency to become extensively 
adherent to the lens capsule — a tendency which, as 
has been stated, is commonly not manifested in the 
iritis of syphilis or of rheumatism. 

Some authors describe a variety of inflammation of 
the iris which they call "spongy iritis" It is, however, 

* In a paper upon the "Pathogeny of Sympathetic Ophthalmia," 
"Archives of Ophthalmology," Vol. XIII, No. 1, 1884. 

f As a result of their painstaking investigation of the pathology 
of herpes zoster, Head and Campbell ("Brain," Vol. XXIII, p. 353) 
assert that these changes consist of "an acute interstitial inflamma- 
tion accompanied by necrosis of the ganglion cells." It is of interest 
to note, further, that they could find no evidence that bacteria play 
any part in either the ganglion or skin lesions, and that they regard 
the latter as being the result of "intense irritation of cells in the 
ganglion which normally subserve the function of pain," and not 
as due to "disturbance of special trophic nerves." If these conclusions 
are correct, their important bearing upon the etiology of sympathetic 
inflammation is obvious. (For a fuller consideration of this ques- 
tion, see a paper by the author upon "The Genesis of Sympathetic 
Ophthalmitis," published in the "Journal of the American Medical 
Association," Jan. 28, 1905.) 



260 



PREVALENT DISEASES 'OF THE EYE 



only a type of the plastic variety, in which there occurs a 
low form of plastic exudation in the anterior chamber, 
that presents a cyst-like appearance, and might be 
mistaken for a dislocated lens. Such cases are com- 
monly of rheumatic origin. 

A chronic form of plastic iritis is occasionally met with, 
in which the inflammatory symptoms are but slightly 
marked. It is often associated with a rheumatic or 
gouty diathesis, and shows a disposition to recurrence. 
Points of adhesion between the iris and lens are apt to 
take place before the true nature of the attack is dis- 
covered, as it develops insidiously, and is unattended 
by pain or other symptoms calculated to alarm the 
patient and induce him to seek medical advice. 

Treatment. — In the treatment of iritis in general the 
indications are to control and overcome the inflamma- 
tion as quickly as possible, and, by the use of a mydri- 
atic, to keep the pupil widely dilated, so that adhesions 
shall not form between the posterior surface of the iris 
and the lens capsule. Nearly always constitutional 
as well as local measures are called for. The most 
important local remedy is atropin. Four grains to the 
ounce (about one per cent.) is the strength of the solution 
of atropin usually employed. In the different varieties 
of plastic and purulent iritis it must be used freely, 
the frequency of the applications being determined 
chiefly by the state of the pupil and the amount of 
ciliary neuralgia and photophobia. When there are 
recent pupillary adhesions, which we hope to break up 
(for we can usually accomplish this, unless the bands 
are firm and broad), an instillation every hour may be 
required, or even, for a short time, several instillations 
an hour may be permissible. Such frequent applica- 
tions, however, can not be long continued without the 



DISEASES OF THE IRIS AND CILIARY BODY. 26l 

constitutional effects of the drug becoming manifest, 
and, as cases of marked individual susceptibility to the 
action of belladonna are occasionally met with, due 
caution should be exercised in using atropin in this man- 
ner. Ordinarily, four to six applications a day are 
sufficient. In serous iritis atropin should not be used 
so frequently or in such strong solution, since in this 
affection the pupil yields readily to its influence, and 
moreover, owing to the tendency to increased intra- 
ocular tension which characterizes this disease, there is 
danger that its too liberal use may precipitate a 
glaucomatous condition. 

Especially in plastic iritis, dionin, used in conjunction 
with atropin, is often beneficial, since it not only lessens 
the pain, and promotes the absorption of inflammatory 
products, but increases the mydriatic effect of the 
atropin. It may be used as often as three times a day 
in five per cent, solution. 

Occasionally individuals are met with in whom atro- 
pin fails to produce a mydriatic effect, and others in 
whom it greatly irritates the conjunctiva, a few applica- 
tions producing a conjunctivitis, which may be attended 
by an erythematous inflammation of the lids and cheek. 
Under such circumstances hyoscyamin hydrobromate 
or duboisin sulphate may be substituted for atropin. 
As these mydriatics, especially the latter, are more apt to 
produce constitutional effects when applied to the eye 
than atropin, greater caution is required in their use. 
Two grains to the ounce will usually be a strong 
enough solution of either of these to employ, and this 
should not be applied more than three or four times a 
day. 

In many cases of iritis no other local treatment than 
the employment of a mydriatic is required; but, when 



262 PREVALENT DISEASES OF THE EYE. 

the inflammation is of severe tvpe, the application of 
three or four leeches to the temple may accomplish 
good, and, when there is severe pain, much relief is often 
experienced from the use of a lotion of opium (ext. opii, 
gr. x.-xv; aquae, §iv) or of belladonna (ext. bella- 
donnas, gr. xv; aquae, §iv), which should be applied 
to the closed lids more or less constantly upon a pad of 
gauze or soft linen. The application in the same way, 
for half an hour at a time several times a day, of water 
as hot as can be borne is also a useful expedient under 
the same circumstances. In obstinate cases, more 
especially those of syphilitic origin, it is well to supple- 
ment the use of constitutional remedies by the applica- 
tion to the forehead and temples, two or three times a 
day, of mercurial ointment, to which extract of bella- 
donna or extract of opium may be added in the pro- 
portion of oj-ij to Bj. 

Of constitutional remedies, the most valuable are 
mercury, potassium iodid, and the salicylates. If to 
this list are added quinin, which is especiallv useful in 
purulent iritis; opium, which seems not only to control 
the pain, but favorably to influence the inflammation; 
pilocarpin hydrochlorate, which is useful especially when 
there is increased intraocular tension; and some brisk 
purgative combination which, as a rule, should contain* 
calomel, it will comprise all the drugs that are likely to 
be needed in treating any of the varieties of the disease. 
A supplemental list of less important but at times useful 
remedies would include arsenic, colchicum, lithia, iron 
and the Turkish bath. 

In acute plastic iritis, whether of specific or non- 
specific origin, sodium or lithium salicylate, given in 
liberal doses (gr. x to xv every two or three hours, 
according to the susceptibility of the patient"), is, on 



DISEASES OF THE IRIS AND CILIARY BODY. 263 

the whole, the most promptly efficacious remedy that 
we have. In many cases, and especially in those of 
rheumatic origin, it not only relieves the pain very 
quickly, but hastens the resolution of the inflammation 
and promotes the absorption of effused material. 

In svphilitic iritis, whether the disease be inherited 
or acquired, mercury in some form is usually demanded. 
It is also our chief reliance in sympathetic iritis, and is 
more useful than anything else — unless it be potassium 
iodid — in the iritis of herpes zoster ophthalmicus and 
in theother" trophic" nerve varieties. In the acute stage 
of syphilitic iritis it should be administered liberally, 
and in such shape as to impress the system promptly. 
Salivation is to be avoided, but in severe cases we 
must not stop far short of it. Small doses of calomel, 
frequently repeated (gr. \ every hour, or gr. ss. every 
three hours), supplemented, if necessary, by inunctions 
of mercurial ointment, afford the best means of accom- 
plishing the desired result. There seem to be no contra- 
indications to the administration of sodium salicylate 
and mercury at the same time, and I have obtained 
good results in this w T ay. Opium may be given if the 
pain is severe, or if a purgative effect is produced by the 
mercury. In subacute cases, or when the symptoms are 
less urgent, biniodid of mercury, in doses varying from 
gr. 2V to gr. T V, may be given three times a day. This 
is a very efficacious and convenient method of admin- 
istering mercury, and salivation is less apt to occur than 
when calomel is employed. It may be given in tablet 
triturates or pills, or preferably in solution in water, a 
small quantity of potassium iodid being added to render 
the mercury soluble. When a prolonged course of 
mercury is required this, or the protoiodid, is decidedly 
the best form in which to administer it. 



264 PREVALENT DISEASES OF THE EYE. 

Potassium iodid is valuable in rheumatic iritis, and 
it may also advantageously supplement the use of mer- 
cury in syphilitic iritis. In serous iritis it is the most 
efficacious remedy that we possess, but its good effects 
are not always manifest until it is given in liberal doses. 

In sympathetic iritis the prognosis is grave, whatever 
treatment may be adopted. The most essential thing 
is that it should be commenced with the least possible 
delay. Although, as has been indicated, radically dif- 
ferent views are held as to the etiology of sympathetic 
ophthalmitis, it is generally agreed that the chances 
of controlling the inflammation in the sympathizing 
eye are increased by the removal of the exciting eye. 
The condition of this eye, therefore, should be carefully 
determined, and if it is blind or so nearly blind that 
useful vision with it is impossible, although at the time it 
may be quiescent and apparently free from inflamma- 
tion, it should be enucleated without a moment's un- 
necessary delay. On the other hand, if there is a 
reasonable probability that, with or without operation, 
a useful degree of vision may be retained in this eye, 
it is best not to sacrifice it; for it should be borne in 
mind that instances have occurred in which the sight of 
the sympathizing eye was entirely lost while serviceable 
vision was retained in the primarily affected eye. This 
question, whether or not to enucleate an eye which, 
though not itself sightless, has caused and is promoting 
the development of sympathetic inflammation in its 
fellow, is one of the most perplexing which fall to the 
lot of the ophthalmic surgeon to decide, and it is cer- 
tainly one which no one without his especial training 
should attempt to decide. 

Mercury given liberally, by the mouth and by inunc- 
tion, so as to impress the system rapidly, and, it may 



DISEASES OF THE IRIS AND CILIARY BODY. 265 

be added, given persistently, is the remedy which has 
been chiefly relied upon to combat sympathetic inflam- 
mation, in whatever form it may manifest itself. At 
a later stage potassium iodid may be administered with 
benefit. GifTord, in several cases, has obtained surpris- 
ingly satisfactory results from the administration of 
heroic doses of sodium salicylate — "150 to 200 grains 
in the course of the waking hours."* His experience 
certainly seems to call for further experimentation in 
this direction. 

In purulent iritis, which, as has been said, usually 
follows wounds of the eye or operations upon it, and is 
frequently accompanied by purulent infiltration of the 
cornea, the free administration of quinin sulphate offers 
the best prospect, though not a very promising one, 
of success. Pilocarpin hydrochlorate, which seems to 
be as efficacious when administered by the mouth as 
when introduced into the system by the hypodermic 
method, is sometimes useful in cases of serous iritis, in 
which the tension of the globe is high; and in any of the 
other varieties, if this condition obtains or if there is 
cloudiness of the vitreous humor, it may be administered 
with advantage. I have found it convenient to pre- 
scribe it in a solution of the strength of gr. j to 5j- Ten 
drops of this solution, containing one-sixth of a grain 
of the salt, is the commencing dose, to be taken by the 
mouth, once a day. According to the effect produced, 
the dose is increased by adding each day two or three to 
the number of drops administered. In any severe 
attack of iritis an active cathartic may be given with ad- 
vantage at the commencement of the treatment. A 
very efficacious one is the combination of two to five 

* "Diseases of the Eye, Nose, Throat and Ear,'* Posey and 
Wright, p. 396. 



266 PREVALENT DISEASES OF THE EYE. 

grains of calomel, two grains of scammony, and six of 
powdered rhubarb, already commended. 

When the iritis is dependent upon a gouty diathesis, 
colchicum and the preparations of lithium are use- 
ful; and in the iritis which sometimes follows malarial 
attacks, and in that which accompanies ophthalmic 
shingles, arsenic, in the form of Fowler's solution, 
may be prescribed with benefit. The daily use of 
the Turkish bath is commended by Bull as a valuable 
remedy in arthritic iritis. 

In the management of every case of iritis the question 
arises whether the patient should be confined to the 
house during the continuance of the attack. Undoubt- 
edly, in acute cases, and especially when the inflamma- 
tion is severe, this should be done if practicable. It is 
very rarely necessary, however, that he should be shut 
up in a dark room. With a shade and with dark glasses 
(London-smoke coquilles), he may safely be allowed the 
freedom of the house. This makes the treatment much 
less irksome to the patient, and does not in the least re- 
tard the cure. In subacute cases, and even in acute 
cases when there is but little pain or photophobia, the 
patient need not be confined to the house, unless, of 
course, the weather be unpropitious. Indeed, most 
patients with iritis are treated successfully as "out- 
patients," being seen by the medical attendant either at 
his office or at his hospital clinic. 

Surgical interference is rarely required during the 
active stage of iritis. There are, however, some excep- 
tions to this rule, as, for instance, in serous iritis, when 
the supervention of glaucomatous symptoms may de- 
mand the prompt performance of an iridectomy. To 
remedy the consequences of iritis, however, and to pre- 
vent recurrent attacks, operations upon the eye are 



DISEASES OF THE IRIS AND CILIARY BODY. 267 

frequently called for. When, after an attack of iritis, 
a few slender bands of adhesion between the margin of 
the pupil and the lens are left, probably no ill conse- 
quences will result therefrom, and for such a condition 
no operation is required. If, however, as happens not 
infrequently in neglected cases, the margin of the pupil 
is completely glued to the surface of the lens, an iridec- 
tomy should be performed without unnecessary delay, for 
soon the iris will be bulged forward by the accumulation 
of fluid behind it (see Fig. 107), and will undergo 
atrophy, while at the same time the deeper structures 
of the eye will suffer from the consequent disturb- 
ance of their nutrition. When, though not completely 
adherent, the margin of the pupil is attached to the 
lens by several broad bands, an iridectomy may be re- 
quired, since recurrent attacks of inflammation are not 
infrequently induced in consequence of the irritation 
caused by the traction of these bands during the 
muscular movements of the iris. 

When the pupil is closed, or is occluded by an organ- 
ized exudate, an iridectomy is positively indicated, and, 
by yielding a clear artificial pupil, may restore almost 
normal vision to a nearly blind eye. If, however, the 
pupillary occlusion is attended, as it sometimes is after 
the more severe types of iritis, with adhesion of nearly 
the entire posterior surface of the iris to the lens capsule 
(see Fig. 104), the outcome of an iridectomy is apt to 
be much less satisfactory; for under such circumstances 
it is very difficult to obtain a clear pupil, since it 
frequently happens that the iris tissue is so friable that 
it can not be drawn out by the forceps, or the muscular 
coat only yields to the traction, while the pigment coat 
remains attached to the lens capsule. There is great 
danger, too, that the new pupil, if we are so fortunate 



2 68 



PREVALENT DISEASES OF THE EYE. 



as to secure one, will become occluded as a result of 
the inflammation arising from the performance of the 
iridectomy. 

DISEASES OF THE CILIARY BODY. 

Cyclitis.— Inflammation of the ciliary body, or 
cyclitis, though of common occurrence, is seldom met. 
with as a disease per se. Usually it is but part of a 
more general inflammation of the uveal tract— of a 
choroiditis it may be, though oftener it occurs in associ- 
ation with iritis; indeed, it is present in most cases of 
severe iritis, especially those of syphilitic origin. 

In cyclitis, as in iritis, the inflammation may be of 
plastic, or it may be of purulent or serous, type. Plastic 
cyclitis is commonly due to syphilis or to rheumatism; 
it also occurs, and in its worst form, in sympathetic 
ophthalmitis. Purulent cyclitis usually arises from 
penetrating wounds of the ciliary region or of the cornea 
and iris. It may occur also as a complication in opera- 
tions, such as extraction of cataract, which involve 
opening of the eyeball. It is always a consequence of 
infection, and it leads commonly to a general suppura- 
tive inflammation of the eye — panophthalmitis, — result- 
ing in destruction of sight and ultimately in atrophy of 
the eyeball. Serous cyclitis is invariably but part of a 
general uveitis, which condition has been treated of 
already under the head of " serous iritis. " 

Intense pain, great photophobia, and, especially, 
exquisite sensitiveness of the ciliary region, together 
with marked pericorneal injection, are the character- 
istic signs of plastic and of purulent cyclitis, while de- 
cided impairment of vision is usual in all three varieties, 
owing to the cloudiness of the vitreous humor which 
is commonly present. 



DISEASES OF THE IRIS AND CILIARY BODY. 269 

Treatment. — The treatment of the different varieties 
of cyclitis, constitutional as well as local, is the same as 
in the corresponding types of iritis, mercury, the sali- 
cylates, and potassium iodid being indicated in the 
plastic and serous forms, and quinin in generous doses 
in the purulent form, while atropin in strong solution, 
dionin, and the lotion of opium are called for in the 
first and last named varieties. 

In purulent panophthalmitis (see Fig. 130) prompt 
enucleation of the eye, which saves the patient from 
much intense suffering, is indicated. The risk of 
cerebral infection, which is supposed to attend the per- 
formance of the operation under such circumstances, 
is probably not appreciably greater than that to which 
the patient is exposed through retention of the suppurat- 
ing eye. 

Tumors of the ciliary body, sarcomatous growths 
more especially, are not so rare as tumors of the iris. 
Their early diagnosis, which is of the utmost importance, 
can be made only by means of the ophthalmoscope. 
When they are of malignant character, immediate 
enucleation of the eye is demanded. 

Enucleation of the Eyeball. — One of the most 
definite advances in ophthalmic surgery in recent years 
is the method, now universally employed, of removing 
the eyeball. 

The modern operation, known as "enucleation" of 
the eye, was devised by Bonnet, in 1841. The operation 
of "extirpation" of the eye, previously practised, a prim- 
itive and rude procedure, is aptly described by Fuchs as 
" cutting out the eyeball, together with the neighboring 
soft parts, in a not very different way from that in 
which a butcher is accustomed to do it." 

The chief end in view, and a most important one, in 



270 PREVALENT DISEASES OF THE EYE. 

the operation of "enucleation" is the preservation of 
all the soft parts contained in the orbit, especially the 
preservation of the conjunctiva and the muscles con- 
cerned in the movements of the globe, so that only the 
eyeball itself, freed from all its connections, is removed. 
This results in securing a relatively large cavity, lined 
by mucous membrane, — the conjunctiva, — well adapted 
to receive an artificial eye of the requisite size, 
and a movable "stump," made up of the preserved 
muscles, Tenon's capsule, and the fatty tissue of the 





Fig. 109. — Bader's scleral fixation forceps. The long, sharp teeth bite 
into the sclera, and for this reason they are invaluable in the last step of 
enucleation of the eye — the division of the optic nerve. 



orbit, which not only gives to the artificial eye a much- 
desired prominence, but enables it, at least in consider- 
able measure, to follow in a natural way the excursions 
of the seeing eye. 

The several steps of the operation, which, except 
when panophthalmitis is present or perforation of the 
globe has occurred, for example, from sloughing of the 
cornea, is a very simple surgical procedure, are well 
shown in the accompanying illustrations. 

A general anesthetic and careful antiseptic pre- 
cautions, of course, are demanded. The instruments 
required are a stop-speculum, a strabismus-hook. 



DISEASES OF THE IRIS AND CILIARY BODY. 



2 7 I 



stout, blunt-pointed, scissors, curved on the flat, a pair — 
preferably two pairs — of ordinary fixation forceps, and 




Fig. no. — Enucleation of eye. The first step — the circumcorneal section 
of the conjunctiva — completed. 




Fig. in. — Enucleation of the eye. The second step — dissection of the recti 
muscles from their scleral attachment. 



the scleral fixation forceps of Bader, shown in the cut — 
Fig. 109. 



272 PREVALENT DISEASES OF THE EYE. 

With the fixation forceps and the scissors the cir- 
cumcorneal section of the conjunctiva (Fig. no) is 
easily made — the second pair of fixation forceps often 
being found useful to rotate the eve into a convenient 
position for seizing, with the other pair, the portion of 
the conjunctiva we wish to divide. This step com- 
pleted, it is well, with the scissors, to separate the con- 
junctiva, in every direction, rather widely from the ball, 
so that the second step, the dissection of the recti 




Fig. 112. — Briucleation of the eye. Division of the optic nerve, the eyeball 
strongly rotated outward by means of Bader's scleral fixation forceps. 

muscles from their scleral attachment (Fig. in), may 
be more readily accomplished. 

The final step — the division of the optic nerve (Fig. 
112) — is not so easily executed, unless provision has been 
made for exerting traction upon the eyeball, so as to 
put the nerve somewhat upon the stretch. There are 
several ways of accomplishing this; but, to my mind, 
the most satisfactory is that shown in Fig. 112 — the 
employment of the scleral fixation forceps of Bader. 
These forceps, it mav be added, are especially helpful 
when it is desirable to sever the optic nerve at a con- 



DISEASES OF THE IRIS AND CILIARY BODY. 2J$ 

siderable distance behind the scleral, as in enucleation 
for malignant intraocular growths or for sympathetic 
ophthalmitis. 

Considerable hemorrhao;e follows the division of the 
optic nerve and the ciliary vessels that surround it, but, 
after the ball has been completely removed from the 
orbit bv severing the attachments of the oblique 
muscles and any other adherent tissue, this is easily 
controlled by firm compression. 

The after-treatment is very simple, and recovery from 
the operation, which is attended by little or no shock, 
astonishingly prompt. Sterile gauze "sponges" are 
applied over the lids — somewhat in the fashion of a 
graduated compress — and over these a tight bandage 
(Fig. 10). The next morning these compresses are 
removed, and a gauze pad, wet with a saturated solution 
of boracic acid, is applied in their stead, and is kept wet 
by repeated applications of the boracic solution. 

As soon as the patient has recovered sufficiently from 
the effects of the anesthetic to wish to do so, he is per- 
mitted to sit up, and after three or four davs a mon- 
ocular eve-shade is substituted for the wet pad and ban- 
dage. A collyrium of alum and boracic acid (alum., gr. 
iij; acid, boracic, gr. xij; aqua? destil., 5j),to be dropped 
into the conjunctival sac three times a day, is now 
prescribed, and the patient, if he desires, may leave the 
hospital; and, at the expiration of a month from the date 
of the operation, he may begin to wear an artificial eye. 

It is the practice of some surgeons, after the eye is 
removed, to bring together the edges of the conjunctival 
wound by means of a continuous suture, and others, 
more reprehensibly still, pack the orbit with sterile 
gauze. Both of these measures are as uncalled for as 
they are objectionable; and, in my opinion, the same 



274 PREVALENT DISEASES OF THE EYE. 

criticism applies, because of the unnecessary traumatism 
involved, to the "finicky" procedures, supposed to in- 
crease the mobility of the "stump," of Suker, Schmidt, 
Priestley Smith, and others. 



CHAPTER VIII. 
GLAUCOMA. 

Of all the diseases of the eye there is none that it is 
more important the general practitioner should be able 
to diagnosticate than glaucoma; for it is an affection 
that frequently runs so rapid a course that failure to 
recognize it, and to employ promptly the proper remedial 
measures, may result, in a few days, in irreparable 
blindness. It is not a disease, however, which, if it 
can be avoided, he should undertake to treat, since its 
proper management calls for the skill of the trained 
specialist. Still, as its onset is so often sudden, he is 
liable to be called upon at any time, especially in sections 
of the country remote from large centers of population, 
to recognize it, to point out its serious nature, and, at 
least, to suggest temporary measures of relief; and this 
much, unquestionably, he should be capable of doing. 

As is well known, the essential feature of glaucoma 
is an increase in the intraocular tension — a hardening 
of the eyeball. This increase of tension may be slight 
and continuous or it may be excessive and intermittent 
in character. When it is pronounced, it is attended 
by certain characteristic symptoms which are not diffi- 
cult of recognition. The severity of an attack of glau- 
coma and the amount of impairment of sight depend 
largely upon the degree of hardening of the eyeball. 
The impairment of vision is due to clouding of the 
media of the eye, to the pressure to which the optic 
nerve is subjected, and to interference with the blood- 

275 



276 PREVALENT DISEASES OF THE EYE. 

supplv of the choroid and retina; the pain, which is 
often excessive, is largely the direct result of the 
increased tension. 

There are two markedly different types of glaucoma — 
inflammatory glaucoma and simple glaucoma. These 
differ radically in their clinical features, in the treatment 
which they demand, and, probably, not less radically 
in their etiology. Besides these two varieties of "pri- 
mary " glaucoma, certain inflammatory affections of the 
eve, and many traumatic lesions as well, mav be com- 
plicated bv an increase of intraocular tension, to which 
condition the name "secondary" glaucoma is applied. 

Although secondary glaucoma mav manifest itselt 
at any period of life, primary glaucoma, of either variety, 
is extremely rare under thirty years of age, and is often- 
est encountered in persons who have reached, or have 
passed, middle life. At the outset primary glaucoma is 
commonly monocular, but, sooner or later, both eves 
are almost sure to become involved. In the rare in- 
stances in which increased intraocular tension is met 
with in the voung there commonly occurs a gradual dis- 
tention of the sclerotic coat and cornea, so that the whole 
eveball becomes enlarged. Under such circumstances 
the depth of the anterior chamber is usually consider- 
ably increased, and the pupil and the iris itself are larger 
than normal. This condition, which is known as bupk- 
thalmos, is not infrenuentlv of congenital origin iFig. 
113. The enlargement of the ball finds its explanation 
in the tact that in the young the external tunic of the 
eve is less tough than in the adult, and. therefore, yields 
to the continued intraocular pressure. 

Inflammatory Glaucoma Glaucoma with Ex- 
acerbations . — It is this variety of glaucoma, with its 
pronounced inflammatory symptoms, that not infre- 



GLAUCOMA 






quentlv leads to rapid destruction of sight, though 
usually this is not the outcome of a hrst attack; for, 
as the subtitle siren above indicates, the disease is com- 
monlv intermittent in character, though the periods 
of intermission are wholly irregular. 

The symptoms, subjective and objective, of a well- 
marked attack of inflammatory glaucoma are very 
characteristic. Severe pain, supraorbital and hemi- 
cranial as well as ocular, accompanied at times by 
nausea and vomiting;: more or less complete anesthesia 
of the cornea;* pronounced imoairment of vision, and. 




Fig. 113. — Buphthalmos (Haab). 

when the sight is not too profoundly affected, the 
appearance ot a halo,, showing the rainbow colors, 
about the flame of a candle or a lighted match, 
are the chief subjective symptoms. The objective 
symptoms | Plate VII, Fig. 2) are marked peri- 
corneal and general conjunctival injection; steam- 
iness of the cornea, reminding one of the appearance 
produced bv breathing upon a plate of cold glass; 
great enlargement of the pupil, which is often irregularly 

* The sensibility of the cornea can be tested conveniently bv 
touching it lightly with a slender spill of tissue or other thin paper. 



278 PREVALENT DISEASES OF THE EYE. 

oval in shape, and shows little or no response to light; 
partial or complete obliteration of the anterior chamber, 
due to the lens and iris being pressed forward against 
the cornea; undue pupillary reflex, suggestive of opacity 
of the lens, and, above all, increased tension of the 
globe, easily detected by palpation through the upper 
lid while the eye is directed downward (see Fig. 4). 
The pain and injection of the ball are not characteristic, 
for they are not different from the pain and injection 




Fig. 114. — Ophthalmoscopic appearance of the optic disc in advanced glau- 
coma (Jaeger). 



encountered in iritis, in cyclitis, and in severe keratitis; 
but in these conditions we have a contracted, not a 
dilated, pupil, an anterior chamber of normal depth, 
no anesthesia of the cornea, and commonly no increase 
of intraocular tension. 

Although during the premonitory stage of glaucoma 
and in the intervals between the exacerbations an 
ophthalmoscopic examination is usually required to 
establish the diagnosis (Fig. 114), it is of little value 



GLAUCOMA. 279 

during the height of an acute attack; for then the 
media are too cloudy to permit an inspection of the 
fundus of the eye, and, besides, the symptoms are so 
pathognomonic that the information which the oph- 
thalmoscope affords under other circumstances is not 
missed. 

Before the onset of such a severe attack as has been 
described, several, perhaps many, less marked exacer- 
bations, in all probability, will have occurred, and the 
true character of these is not so easily recognized by 
the physician who is but little versed in the management 
of diseases of the eye. Among the earliest of the pro- 
dromal symptoms of inflammatory glaucoma is a rapid 
failure of the accommodative power of the eye, necessi- 
tating, at short intervals, an increase in the strength of 
the glasses worn in near vision. Then there occurs, 
in connection, perhaps, with an attack of indigestion 
or after prolonged use of the eyes, a transient obscura- 
tion of vision, attended by slight supraorbital pain and 
some pericorneal injection. If an examination of the 
eye is made at this time, a perceptible hardening of 
the ball will be detected, and a test with the candle 
flame will show the rainbow-colored halo. The oph- 
thalmoscope would show, besides, a jerky pulse in the 
central retinal veins or, perhaps, a slight arterial pulse. 
After a night's rest the eye will have returned nearly 
or quite to its normal condition, and some weeks may 
elapse before a similar, but probably more pronounced, 
attack occurs. The recovery from this next exacerba- 
tion will be less prompt, and after several such attacks 
a perimetric test will reveal a perceptible contraction 
of the nasal half of the field of vision, and the ophthal- 
moscope will show a depression of the optic disc — the 
beginning of a glaucomatous "cup" (Fig. 115). After 



280 PREVALENT DISEASES OF THE EYE. 

another interval of uncertain length, and again pre- 
cipitated by some exciting cause, such as overstrain of 
the eyes, a spell of crying, etc., there will occur a well- 
marked attack of glaucoma, and after this has subsided, 
if it does subside without radical treatment, vision will 
remain more or less seriously impaired. 

Such is the usual history 7 of a case of inflammatory 
glaucoma, until, in the course of time, a much more 
severe attack occurs, and sight is permanently lost. 
But even when this has happened the disease has 




Fig. 115. — Section of optic nerve-head showing deep glaucomatous exca- 
vation (Lippincott). 

not run its course, and much suffering is still in store 
for the unfortunate individual; for many acute exacer- 
bations, caused by a temporary increase in the tension 
of the eye, and accompanied by intense pain, are liable 
to occur, until finally, the lens having already become 
cataractous, the eyeball undergoes partial atrophy, 
becomes abnormally soft, and remains comparatively 
quiescent. It is still, however, a source of danger, 
since in not a few instances such a blind and atrophied 



GLAUCOMA. 28l 

eye has been known to induce sympathetic ophthal- 
mitis in the fellow-eye. 

From the foregoing description it is evident that there 
is little excuse for mistaking inflammatory glaucoma 
for iritis, cyclitis, or keratitis, and still less for conjuncti- 
vitis. For confounding it with cataract, as the experi- 
ence of every ophthalmic surgeon shows is done not 
very rarely, there is, of course, no excuse whatever, 
since cataract, unless complicated by other disease of 
the eye, is never attended by pain, injection of the ball, 
or other evidences of inflammation. To mistake it for 
a severe attack of facial neuralgia is less reprehensible; 
but such an error can be made only when one neglects 
to examine the eye, and so fails to note the steamy cor- 
nea, the enlarged pupil, the shallow anterior chamber, 
and the increased tension of the globe. 

Let the general practitioner but once realize that 
glaucoma is to be suspected, and to be carefully searched 
for, whenever a painful inflammation of the eye 
attended by obscuration of sight is encountered in an 
individual who has reached, or has passed, middle 
life, and errors in diagnosis such as have been 
mentioned will become very rare indeed, and both 
his own reputation and the welfare of his patients will 
be great gainers thereby. 

Much careful research has been undertaken with the 
view of throwing light upon the etiology of inflammatory 
glaucoma, but our knowledge upon the subject is as 
yet far from exact. In order to a clear comprehension 
of the matter, it must be borne in mind that there is a 
constant and very considerable flow of lymph through 
the chambers of the eye. This lymph-stream, which 
is necessary to maintain the non-vascular media of the 
eye — the vitreous humor, the crystalline lens, and the 



282 PREVALENT DISEASES OF THE EYE. 

cornea — in a normal condition, is supplied in large part 
by the very vascular uveal coat, composed of the choroid, 
the ciliary body, and the iris. In the main the direction 
of the current is forward — from the vitreous chamber, 
through the circumlental space and through the pupil, 
to the anterior chamber, where it accumulates in con- 
siderable quantity as the aqueous humor (Fig. 116). 
Having performed its office the lymph must escape from 
the eye, and this is provided for by the existence of 
certain drainage channels, the chief one being at the 
periphery of the anterior chamber, where there are 
numerous "lymph-spaces" which connect with the 
canal of Schlemm. In addition, there are the 




Fig. 116. — Direction of intraocular lymph-stream (Jackson). 

lymphatic vessels which accompany the venae vorticosae 
in their passage through the sclera, and the lymph- 
spaces which surround the optic nerve. 

In order that the intraocular tension may be main- 
tained at its normal standard, it is evident that an equi- 
librium must exist between the inflow and the outflow 
of this lymph-stream. If the inflow does not equal 
the outflow, the intraocular tension will be reduced, the 
eye will be abnormally soft; on the other hand, if the 
conditions are reversed the tension will be increased, 
the eye will be abnormally hard. A hardening of the 
eyeball, in other words, a glaucomatous condition, it will 
be seen, may be brought about in either of two ways 



GLAUCOMA. 283 

— by an increase in the inflow of lymph beyond the 
normal capacity of the drainage apparatus, or by an ob- 
struction or clogging of the outflow channels whereby the 
escape of lymph is impeded. It is probable that both 
of these conditions — an increase in the inflow and an 
obstruction of the outflow of lymph — are concerned in 
the causation of many cases of inflammatory glaucoma, 




Fig. 117. — Section of iris and ciliary body in recent inflammatory glau- 
coma, showing obliteration of the filtration angle. Magnified 9X1 (Fuchs). 
The ciliary process, c, is so greatly swollen that it pushes the root of the iris 
forward and presses it against the sclera, S, and the cornea, C. The sinus of 
the anterior chamber, which should lie somewhat behind Schlemm's canal, s, 
is thus closed. The ciliary muscle shows the pronounced development of 
the circular muscular fibers (Miiller's portion), characteristic of the hyper- 
metropic eye. 

though the inclination at the present day is to regard 
the latter condition as the more potent factor. 

It would be out of place to enter into a discussion of 
the many theories which have been advanced to ex- 
plain the production of glaucoma. The view most 
widely accepted is that the hardening of the eyeball is 
due to obstruction of the lymph-spaces about the 
periphery of the anterior chamber, the so-called filtra- 
tion angle (Figs. 117 and 118). Another view attaches 
more importance to compression of the lymphatic 



284 PREVALENT DISEASES OF THE EYE. 

vessels which pass through the sclera with the venae 
vorticosae; another, to narrowing of the circumlental 
space, which has a normal width of but half a milli- 
meter, whereby the flow of lymph from the vitreous 
chamber to the aqueous chamber is obstructed; while 



Fig. 118. — Section of iris and ciliary body in advanced inflammatory 
glaucoma, showing atrophy of the iris and adhesion of its periphery to the 
sclera and cornea, also pronounced atrophy of the ciliary body. Magnified 9X1 
(Fuchs) . The dotted line gives the outline of the iris, I v and the ciliary body, 
c v in the normal condition. The root of the iris is adherent to the sclera, S, 
and the cornea, C, wherever it has been pressed against them by the ciliary 
body. The attachment of the iris is hence displaced forward and lies in 
front of Schlemm's canal, s. So, too, the sinus of the anterior chamber is 
displaced from b to a. Wherever the iris has become adherent, it has been 
thinned through atrophy, so that in places — b, for example — it consists of 
scarcely anything more than the pigment layer. Even the free portion of the 
iris, I, appears, in consequence of its atrophy, narrower than the normal iris, I v 
Over the pupillary border, e, the retinal layer of pigment turns forward 
farther than usual, and the sphincter pupillae, p, also shares to some extent 
in this eversion. The ciliary body, owing to its having become atrophic, 
has again separated from the iris, and in fact more so than in the normal con- 
dition, so that it is now removed from the iris by a broad interval. The 
atrophy affects both the ciliary muscle, m, and the ciliary process, c. 

still another maintains that under certain circumstances 
there is an alteration in the consistency of the lymph 
— a serosity — which interferes with its escape through 
the drainage channels. 

Those, of whom I am one, who consider that an in- 



GLAUCOMA. 285 

crease in the lymph-stream, a hypersecretion of lymph, 
is not infrequently a factor in the production of glauco- 
matous tension, believe that this increase is often 
brought about, through the resulting hyperemia of the 
uveal coat, by the strain of accommodation due to errors 
of refraction. It is a well-known fact that hypermetro- 
pic eyes are especially disposed to develop glaucoma, 
though this has been explained upon the ground that 
in such eyes the circumlental space is narrower than 
in the emmetropic or myopic eye. The frequency with 
which astigmatism, and especially astigmatism "against 
the rule," — a refractive error which gives rise to an 
exceptional amount of accommodative strain, — is found 
in association with glaucoma, attracted my attention 
many years ago, and was made the subject of a com- 
munication to the American Ophthalmological So- 
ciety.* In this connection the fact, to which reference 
has been made, that attacks of glaucoma are frequently 
precipitated by prolonged use of the eyes in near work — 
reading, writing, etc. — is significant. 

Among the general conditions which are regarded 
as favoring the development of glaucoma may be men- 
tioned, rheumatism, gout, angiosclerosis, and the meno- 
pause. It should be mentioned also that the employ- 
ment of a mydriatic in persons predisposed to glaucoma 
has been known frequently to precipitate an attack of 
the disease, the explanation being that when the pupil 
is widely dilated the iris is crowded into the periphery 
of the anterior chamber in such a manner as to obstruct 
the filtration angle. For this reason, the indiscrimi- 
nate use of mydriatics in persons beyond middle life 
is regarded as reprehensible. 

Writers commonly subdivide inflammatory glaucoma 
* Transactions American Ophthalmological Soc, 1888. 



286 PREVALENT DISEASES OF THE EYE. 

into three varieties — acute, subacute, and chronic. 
These subdivisions are more or less artificial, though 
they serve to emphasize the fact that in some instances 
the disease runs a rapid course, the exacerbations are of 
frequent occurrence and severe in character, and vision 
is soon destroyed; while in others the attacks occur 
at long intervals, and are comparatively mild, so that 
a much longer time elapses before sight is seriously 
impaired (Fig. 119). In what is known as "fulmi- 
nating glaucoma" all the symptoms are greatly inten- 
sified, and sight may be destroyed in the brief period of 




Fig. 1 19. — Chronic inflammatory glaucoma, advanced stage (Ramsay). 

forty-eight or even twentv-four hours. One of the most 
unpromising types of inflammatory glaucoma is that 
which is attended by recurrent intraocular hemor- 
rhages — from the retinal vessels chieflv — and which, 
therefore, is known as "hemorrhagic glaucoma. " 
"Malignant glaucoma" is a term chiefly employed by 
ophthalmic surgeons, it would seem, to characterize 
cases upon which thev have operated unsuccessfullv. 
The' impairment of vision in advanced glaucoma 
frequently exhibits a characteristic which is very strik- 
ing. One of the earlv symptoms of the disease, as has 
been pointed out, is a narrowing of the nasal half of the 



GLAUCOMA. 287 

visual field. In time this contraction of the field be- 
comes general, and slowly progresses toward the point 
of fixation. As a result of this, in extreme cases, vision 
is lost everywhere except at the fovea. Under such cir- 
cumstances the sight is much like that which one obtains 
in looking through a long, narrow tube, a gun-barrel, 
for example. Persons in this condition, though on the 
street they may seem to be quite blind, and have to be 
led about, often are able to distinguish comparatively 
small test-letters at twenty feet, when, after considerable 
difficulty, they have succeeded in "finding" them, and 
fixing their gaze directly upon them. 

Treatment. — The sovereign remedy in the treatment 
of inflammatory glaucoma is the operation of iridectomy, 
and the sooner this is performed the more favorable 
is the prognosis. For this reason it is inadmissible 
for the general practitioner to lose valuable time in 
endeavoring to combat the disease by less efficient 
measures. On the contrary, it is incumbent upon him 
as soon as he has recognized its true character to refer 
the case, with the least possible delay, to the ophthalmic 
surgeon. To undertake the performance of the opera- 
tion himself would be justifiable only if it were imprac- 
ticable for him to do otherwise; for there are few opera- 
tions in ophthalmic surgery which call more distinctly 
for especial skill and training than an iridectomy for 
glaucoma, particularly if it has to be done, as is often 
the case, during an acute exacerbation of the disease. 
The most favorable opportunity for the performance 
of the iridectomy is between the exacerbations: but, 
if the attack is a severe one, it is not permissible to 
defer the operation until the eye has become quiet, 
for before this happens serious and permanent damage 
may have been done to the sight. 



288 PREVALENT DISEASES OF THE EYE. 

There are, however, certain measures which the 
physician under whose observation the case first comes 
should employ without delay, and which, possibly, 
may cut short the attack, or, if they do not accomplish 
this, may, at least, lessen its severity, and so place the 
eye in a more favorable condition for operation. In 
the first place, he should prescribe a solution of eserin 
for application to the eye. The good which eserin 
accomplishes in glaucoma is due to its mechanical effect 
upon the iris. As atropin tends to induce glaucoma 
by dilating the pupil, and thereby crowding the iris into 
the periphery of the anterior chamber, eserin tends to 
reduce increased tension by contracting the pupil, and 
drawing the iris away from the filtration angle. To ob- 
tain the desired effect, therefore, eserin must be used 
in such strength as to cause decided contraction of the 
pupil. 

During an acute attack of glaucoma it is usually 
difficult, and not infrequently impossible, to induce the 
pupil to contract even by the most liberal use of eserin. 
Under such circumstances, therefore, it should be 
prescribed in strong solution — in a solution of the 
strength of four grains to the ounce (eserin sulphate, gr. 
ii; aquae destil., §ss) — and this should be applied from 
three to four times in twenty-four hours. After the 
subsidence of the attack, however, a much weaker 
solution — perhaps only half a grain, or even a quarter 
of a grain, to the ounce — suffices usually to maintain 
the pupil in a state of contraction; therefore such a weak 
solution, the weakest solution, in fact, that will produce 
the desired effect upon the pupil, should be employed 
under such circumstances, and this will probably not 
have to be used more than two or three times a day. 
Another useful local remedy is the lotion of opium, 



GLAUCOMA. 289 

which is apt to be more grateful if applied warm. Di- 
onin, in conjunction with eserin, has also proved useful 
in the acute exacerbations of inflammatory glaucoma, 
through its action as a lymphagogue and an analgesic. 

The constitutional measures called for are the ad- 
ministration, without delay, of an energetic calomel 
purge (calomel, gr. iij-iv; pulv. scammonii virg., gr. 
ij; pulv. rad. rhei, gr. vj), and, when this has had its 
effect, the further administration, in liberal doses, — ten 
grains every two hours — of sodium or lithium salicylate. 
Opium in some form may also be given to lessen the 
pain. 

As has been stated, the prompt employment of these 
measures may control even a well-marked attack of glau- 
coma; but should so fortunate a result ensue it would 
not warrant unnecessary delay in resorting to operation, 
for the outcome of the next attack might be far different. 

As to what may be promised from a well-executed 
and promptly performed iridectomy, it may be said that 
the result usually is extremely satisfactory, and this 
applies not only to the immediate but to the per- 
manent result. If the operation is performed before 
serious damage has been done to the optic nerve 
and retina, the restoration of practicably normal vision 
may be anticipated, as well as complete relief from 
subsequent suffering. But even if so favorable an out- 
come is not to be expected, still the operation should 
be done with as little delay as possible; indeed, it is 
indicated for the relief of suffering, though there may 
be no hope whatever of restoring vision. Exception- 
ally, in the cases of so-called malignant glaucoma, 
iridectomy fails entirely to arrest the progress of the dis- 
ease, and sight is destroyed in a very brief time. When 
this has happened, and the inflammation and pain per- 
19 



29O PREVALENT DISEASES OF THE EYE. 

sist, the eye should be enucleated, as this will put an end 
to all suffering. Fortunately cases of this character are 
extremely rare. 

As inflammatory glaucoma is so invariable a binoc- 
ular affection, every possible precaution should be 
taken when the disease has manifested itself in one eye 
to prevent its occurrence in the fellow-eye. These 
precautions should include, besides care in the use of 
the eyes, regulation of the bowels, and temperance in 
eating and drinking, the careful correction of any re- 
fractive error found to be present, and the use of eserin 
upon the appearance of the first premonitory symptoms 
of the disease. 

Experience has convinced me that not only in dealing 
w T ith the second eye but, if the case can be seen early 
in the prodromal stage, in controlling the development 
of the disease in the primarily affected eye, much is to 
be hoped for from the wearing of accurately adjusted 
glasses — of glasses which exactly correct any refractive 
or muscular anomaly that may be present, and thus 
do away with all strain in both distant and near vision. 

The conviction forced upon me years ago, that com- 
plicated errors of refraction often play an important 
part in the causation 'of glaucoma, has grown stronger 
with more extended observation, and I venture the opin- 
ion that if in the incipient stage of every case of glau- 
coma refractive and muscular anomalies were carefully 
searched for, and as carefully corrected, there would be 
an appreciable diminution in the number of cases 
demanding operation. To those who have had con- 
siderable experience with refractive anomalies, and know 
how often accommodative strain gives rise not only to 
marked hyperemia but to a low grade of inflammation 
of the inner tunics of the eye, this statement will, 



GLAUCOMA. 29I 

perhaps, not seem extravagant. I would, therefore, 
strongly insist upon the importance of a thorough exam- 
ination of the refraction in every case of incipient glau- 
coma, and especially upon its importance with reference 
to the uninvolved eye, when the disease has manifested 
itself in one eye only. 

Simple Glaucoma (Chronic Non-inflammatory 
Glaucoma). — This disease, which is characterized by 
a slight and persistent increase of the intraocular ten- 
sion, is attended by none of the signs of active inflam- 
mation observed in inflammatory glaucoma. There 
is no pain, no injection, no clouding of the media, 
if we except a very slight diminution in some instances 
of the corneal transparency, and little or no shallowing 
of the anterior chamber, and the pupil, though sluggish 
in its response to light, is but slightly enlarged. The 
increase of tension is often so inconsiderable as to be 
difficult of detection and, though it varies somewhat 
in degree from time to time, it is never very pronounced. 

The first symptom to direct the patient's attention 
to the condition of his eyes is failure of vision. This, 
w T hich at first is scarcely perceptible, progresses slowly, 
until after the lapse of several years sight may be entirely 
lost. As in inflammatory glaucoma, there is early in 
the disease a contraction of the visual field, the nasal 
half of the field being first involved. Like inflammatory 
glaucoma, too, it is an affection of advanced life, being 
seldom observed in persons under forty-five or fifty 
years of age, and it almost invariably attacks both eyes. 
As to its etiology little is known. Gout, rheumatism, 
and angiosclerosis are looked upon as conditions pre- 
disposing to its development. 

An ophthalmoscopic examination and a perimetric 
test of the field of vision are necessary to a diagnosis of 



292 PREVALENT DISEASES OF THE EYE. 

simple glaucoma, and even with these aids it is not 
always easy to distinguish it from simple progressive 
atrophy of the optic nerve. In each of these conditions 
there is contraction of the field of vision and cupping of 
the optic disc; but in progressive atrophy of the nerve 
the contraction of the field does not begin in the nasal 
half, as in simple glaucoma, and the cupping of the 
disc is less marked in proportion to the loss of vision; 
there is, moreover, in simple glaucoma a halo-like ring 
about the disc — a ring of partial choroidal atrophy — 
which is not present in progressive atrophy of the nerve. 

Treatment. — Whatever plan of treatment may be 
employed the prognosis is far from favorable. Iridec- 
tomy is by no means the effective remedy in simple glau- 
coma that it is in the inflammatory type of the disease. 
Indeed, its results are so uncertain that many experi- 
enced ophthalmic surgeons regard it as a measure to 
be resorted to only w T hen all other remedies have been 
tried, and found of no avail. Failure to arrest the 
progress of the disease is not the onlv count that can 
be brought against it; for not rarely it is followed by a 
marked change for the worse in the state of the eye, 
the tension being decidedlv increased, and a condition 
more like inflammatory glaucoma being precipitated, 
which may soon lead to complete destruction of sight. 
Still, as the operation in some instances does unques- 
tionably control the disease, it is a warrantable pro- 
cedure when other remedies have proved ineffectual, 
since, under such circumstances, it offers the only hope 
of preventing certain blindness. 

Some excellent authorities, prominent among them 
being Dr. Charles Stedman Bull, of New York, it 
should be stated, look upon iridectomy in simple glau- 
coma with more favor, and believe that it should be 



GLAUCOMA. 



293 



performed as early in the disease as possible, as soon, 
indeed, as the diagnosis can be established with cer- 
tainty. Sympathectomy, or excision of the superior 
ganglion of the cervical sympathetic nerve, is another 
operative procedure which has been recommended 
in simple glaucoma; but the claims made at first as to its 
utility have not been sustained by wider experience with 
the method. 

The remedial measures, other than operative, are 
the use of eserin in such strength as to maintain the 
pupil in a state of moderate contraction — usually an 
eighth-of-a-grain-, or a quarter-of-a-grain-to-the-ounce 
solution, applied twice a day, will accomplish this; 
the correction of any error of refraction that may be 
present; moderation in the use of the eyes; regulation 
of the bowels, and attention to the condition of the 
system, with special reference to the possible depend- 
ence of the disease upon a rheumatic or gouty diathesis. 
Potassium iodid in moderate doses is especially worthy 
of trial. 

Secondary Glaucoma. — Increased intraocular ten- 
sion consequent upon an injury or upon pre-existent 
disease of the eye is denominated secondary glau- 
coma. The diseases and injuries most apt to lead 
to this condition are those which involve the cornea, 
iris, lens, or ciliary body. Among these may be men- 
tioned, prominently, perforating ulcers and penetrating 
wounds of the cornea, complicated by the formation 
of anterior synechia; neglected iritis, leading to exten- 
sive adhesion of the iris to the lens capsule, and especially 
those cases in which there is complete adhesion of 
the pupillary margin to the capsule, since in these the 
flow of lymph from the vitreous to the aqueous chamber 
is prevented; penetrating wounds of the ciliary region, 



294 PREVALENT DISEASES OF THE EYE. 

followed by prolapse of the ciliary body; and injuries 
causing dislocation of the lens, or rupture of its capsule 
and the consequent formation of a traumatic cataract. 
Intraocular growths, especially those of malignant type, 
such as sarcoma of the ciliary body or choroid coat, 
are also usually attended by increase of intraocular 
tension, and, as has already been stated, this may hap- 
pen also in the course of serous iritis, or uveitis. 

The symptoms and the consequences to sight, if 
the increase of tension is marked and is not soon con- 
trolled, are the same as in the inflammatory type of 
primary glaucoma. 

Treatment. — This will vary with the conditions that 
have induced the glaucomatous tension. Iridectomy 
is indicated if there is anterior or posterior synechia; 
abscission, combined, perhaps, with iridectomy, if 
there is prolapse of the iris or ciliary body; extraction 
of the lens if there is a swollen traumatic cataract; and 
prompt enucleation of the eye if the existence of a 
malignant intraocular growth can be established. 
Sodium salicylate and in some instances mercury are 
very useful, and, especially when there is a traumatic 
cataract, potassium iodid, which promotes the absorp- 
tion of the extruded lens substance. Eserin is seldom 
indicated, though in uveitis, if the pupil is much en- 
larged, it may be used with caution. If employed too 
freely in this condition it may aggravate the iritis, and 
cause the formation of posterior synechia?. The lotion 
of opium, applied hot or cold as may be more grateful 
to the patient, is often of benefit. 



CHAPTER IX. 

DISEASES OF THE CRYSTALLINE LENS AND 
VITREOUS HUMOR. 

DISEASES OF THE CRYSTALLINE LENS. 
Enclosed in its capsule, and held in place by its suspen- 
sory ligament, the zonule of Zinn, the crystalline lens 
lies in the hyaloid fossa, a saucer-like depression on the 
anterior surface of the vitreous humor. The capsule 
of the lens is a highly elastic, homogeneous membrane, 
capable of ofTering great resistance to chemical agents, 
heat (boiling water), and putrefactive influences. 
That part of it which covers the front of the lens, and 
which is known as the anterior capsule, is considerably 
thicker than the posterior half, which lies in contact 
with the vitreous humor. The central portion of the iris, 
the zone of contact varying in width with the size of the 
pupil, rests upon the anterior capsule. Being an 
epithelial structure, like the hair and nails, the lens 
continues to grow throughout life, and is considerably 
larger and heavier in old age than it is in youth. Its 
growth is provided for by the presence beneath the an- 
terior capsule of a layer of cubical epithelial cells, 
which become elongated and converted into the six- 
sided prismatic fibers of which the lens is composed 

(Fig. 120). 

In early life, up to about the thirtieth year, the whole 
lens is soft, the central and cortical portions being of 
the same consistency. After this period, through a 
process of sclerosis affecting the oldest fibers, which 

295 



296 



PREVALENT DISEASES OF THE EYE. 



now constitute only the central portion of the lens, 
there is formed a relatively hard nucleus. At first this 
central nucleus is small in proportion to the size of the 
whole lens, and is but slightly harder than the com- 
paratively thick layer of newly formed lens fibers which 
surrounds it. With advancing age, however, it grows 




Fig. 120. — Meridional section through human crystalline lens (Babuchin) : 
A, Anterior, B, posterior surface; C, C, equatorial region; 1, 1', anterior 
and posterior capsule; 2, epithelium beneath anterior lens-capsule; 3, lens 
substance composed of fibers; 4, transition zone where cells of anterior 
epithelium are converted into lens-fibers; 5, nucleus. 



larger and increases in hardness, so that ultimately it 
constitutes the major part of the lens, the soft cortical 
layer which encloses it being now inconsiderable in 
thickness. Besides this change in its structure, which 
is attended by a diminution of its elasticity and an 
appreciable lessening of its transparency, the lens 
undergoes with advancing years an alteration in form, 



DISEASES OF THE CRYSTALLINE LENS. 297 

becoming flatter and less spherical than in childhood 
and youth. 

These alterations in the structure and shape of the 
lens are of great significance. "Old-sight," or presby- 
opia, results from the loss of elasticity and flattening, 
while the presence or absence of a nucleus is of impor- 
tance in connection with the development of cataract, 
since upon this hinges the character of the operative 
procedure which should be employed. The diminution 
of transparency is chiefly significant — for it does not 
appreciably lessen the acuity of vision — because in the 
aged it not infrequently leads to a mistaken diagnosis 
of cataract, with its attendant unpleasant consequences. 

The lens, being without nutrient vessels, depends 
for its nutrition upon the lymph-stream which is sup- 
plied by the vascular uveal coat. To reach the lens 
the lymph must pass through the capsule, which it does 
chiefly at the equator, while it escapes through the an- 
terior capsule. The maintenance of the lens in a nor- 
mal state, it is evident, will depend upon the quality of 
the pabulum with which it is supplied. If through 
disease of the eye or constitutional disorder the 
intraocular lymph is materially altered in character, 
the lens, especially as to its transparency, is apt to suffer. 

Cataract. — Although originally the name cataract, 
or cataracta, was employed to designate an opacity 
which, above all things, was held not to involve the 
crystalline lens, it is now applied only to opacities which 
are located in the lens. The origin of the name, which 
dates back to medieval times, is interesting: 

The Greeks and Romans believed that the crystalline 
lens was the "seat of vision," and, as they knew that 
sight could be restored by the removal of a cataract, 
they were, perforce, driven to the conclusion that the 



298 PREVALENT DISEASES OF THE EYE. 

opacity which they displaced from behind the pupil 
was not the lens, but an opaque substance which, 
cataract-like, had poured down over its anterior surface. 
Hence the Greek term bypochyma and the Latin term, 
first used in medieval times, cataracta. Astonishing 
as it appears to us in the light of modern methods of 
research, this view was generally accepted up to the 
beginning of the eighteenth century, when Brisseau, 
a French surgeon, dissected the cataractous eve of a 
cadaver upon which he had previously performed the 
operation of depression, and discovered that the opacity 
which he had displaced from behind the pupil was, 
indeed, the crystalline lens. His discovery, which, of 
course, involved the abandonment of the view that the 
lens was essential to sight, was laid before the French 
Academy, but did not receive its endorsement until 
after three years of persistent opposition. 

Cataract, though encountered most frequently in old 
age, occurs at all periods of life; indeed, as is well 
known, it is at times of congenital origin. Of the sev- 
eral classifications of cataract the one of greatest prac- 
tical utility is that which is based upon the time of life 
at which the cataract develops, those which form after 
middle life being denominated senile or hard, and those 
which occur earlier than this juvenile or soft, cataracts, 
the hardness or softness of the cataract being dependent 
upon the presence or absence of a firm nucleus, the 
formation of which has already been described. Cata- 
racts are also classified as general cataracts, those in 
svhich the opacity, sooner or later, involves the whole 
lens, and partial cataracts, in which, as a rule, this does 
not happen. Most cases of congenital and juvenile 
cataract and nearly all cases of senile cataract are "gen- 
eral" cataracts. Partial cataracts include zonular, or 



DISEASES OF THE CRYSTALLINE LENS. 299 

lamellar, cataract, anterior polar cataracts, and pos- 
terior polar cataracts. Again, cataracts may be classi- 
fied with reference to their origin, as congenital cata- 
racts, idiopathic cataracts, complicated cataracts (those 
associated with or dependent upon other disease of the 
eye), traumatic cataracts, and cataracts due to consti- 
tutional disorder; and, still again, with reference to the 
stage of their development, as immature, mature, and 
hypermature cataracts; and, finally, after injuries of 
the lens or operations upon it we have secondary or 
capsular cataracts. 

The significance of the first-mentioned classification 
is in its bearing upon the question of surgical treatment. 
Juvenile cataracts, since they have no hard nucleus, 
need not be removed from the eye, but may be broken 
up with a needle, and will, in time, undergo complete 
absorption. Senile cataracts, on the other hand, must 
be extracted, since their firm nucleus will not undergo 
solution in the fluids of the eye. 

General Cataract. — As has been stated, most cases of 
congenital, of juvenile, and of senile cataract are in- 
cluded under this head; and, it may be added, traumatic 
cataracts also are nearly always of this character. Gen- 
eral cataracts, whether juvenile or senile, and whether of 
idiopathic origin or due to constitutional cause or to 
traumatism, have certain features in common. They 
are all attended by marked and progressive impair- 
ment of sight; excepting those of traumatic origin, 
they are nearly always binocular, though they often do 
not develop in the two eyes concurrently; they are un- 
attended by pain or other evidences of inflammation, 
unless complicated by injury or other disease of the eye; 
and, excepting again those due to traumatism, they are 
usually slow in forming, this being especially true of 



300 PREVALENT DISEASES OF THE EYE. 

senile cataracts, which mav be months or even Years in 
reaching a state of maturitv. The amount of impair- 
ment of vision which thev cause depends upon the den- 
sitv of the opacitv and upon its location in the lens. 
When thev are fullv formed vision is reduced to mere 
perception of light, though there are some exceptions to 
this rule in the case of senile cataracts; but, even when 
quite immature, vision mav be little better than this, 
if the opacitv is in the direct line of sight, that is, if it 
involves the nucleus of the lens or the central portion of 
the anterior or posterior cortex. On the other hand, the 




Fig. 121. — Senile cataract, mature (Haab). 

existence of a considerable amount of opacitv, if limited 
to the peripherv of the lens, is not incompatible with 
normal sight, since this does not obstruct the entrance 
of light into the eve or interfere with the formation of a 
perfect image upon the retina. 

Even in fullv formed cataract (Fig. 12 1), it is 
important to remember, the pupil reacts to light 
almost if not quite as well as in the normal eve. 
W hen this is not the case, or when light perception is 
imperfect or absent, other and more grave disease of 
the eve is indicated. 

As a rule, the cataracts which occur before middle 



DISEASES OF THE CRYSTALLINE LENS. 3OI 

life are whiter and more densely opaque, and, therefore, 
more conspicuous, than are those which develop in the 
aged. Indeed, in some cases of senile cataract, in 
which the nucleus of the lens is large and of amber color, 
the opacity is so inconspicuous that without the aid of 
the ophthalmoscope the true condition may be easily 
overlooked. Juvenile cataracts are also less constantly 
binocular than senile cataracts, and are commonly less 
slow in developing ; and, because they are oftener due 
to other disease of the eye or to constitutional disorder, 
the prognosis in operating upon them is less uniformly 
favorable. 

The presence of a comparatively large central nu- 
cleus, the characteristic feature of senile cataract, is the 
cause of this variety of cataract being less conspicuously 
white than are those which occur in early life. The 
nucleus itself is never white, and is seldom densely 
opaque. Occasionally it is colorless, but much oftener 
it is of a yellowish or amber tint, while at times it is 
almost black. As the layer of opaque cortical substance 
is not very thick, the color of the cataract partakes of that 
of its nucleus, so that we have in the aged yellowish, 
amber-colored, and so-called black cataracts, but rarely 
cataracts that are decidedly white. 

In senile cataract the opacity usually manifests itself 
first in the cortical layers of the lens, and, as has been 
said, it commonly increases slowly, though in rare 
instances striking exceptions to this rule are encountered. 
While I have frequently seen cortical opacities remain 
stationary for years, I have, on the other hand, observed, 
in three instances, a senile cataract change from a state 
of incipiency to a state of maturity in one week's time. 
Doubtless, many old persons go to their graves without 
being aware that, for years, they have had incipient cat- 



302 PREVALENT DISEASES OF THE EYE. 

aracts. This is not so remarkable, however, as the 
fact, of not very rare occurrence, that individuals may 
be blind in one eye from cataract for months, without 
being conscious that such is the case. 

One of the earliest premonitory symptoms of senile 
cataract is the decline of presbyopia, the acquisition 
of so-called "second sight." When a person, who for 
years has been unable to read without presbyopic 
glasses, discovers that he can now put them aside and 
read without their assistance, he usually congratulates 
himself, and is congratulated by his friends, upon this 
restoration of youthful vision. The real significance 
of this change is that cataract is impending, and that in 
consequence of the degeneration of its fibers the lens is 
changing its shape, becoming more convex, and so giv- 
ing rise to an acquired myopia, which enables small 
objects to be seen without the convex glasses that were 
previously required. It goes without saying that this 
improvement in vision is apt to be short-lived, and that 
it is hardly a matter for congratulation. 

Our knowledge concerning the etiology of cataract is 
not as satisfactory as could be wished. We know, how- 
ever, that the process which causes the lens to become 
opaque is a degenerative and not an inflammatory one. 
The lens fibers undergo degeneration, and in doing so 
lose their transparency. This degeneration, whether 
occurring in intrauterine life, in youth, or in old age, 
is commonly the result of faulty nutrition, which may 
be due to disease of the eye itself, to constitutional 
disorder, or to senile decay. Among the constitutional 
disorders which predispose to the development of 
cataract may be mentioned diabetes, inherited syphilis, 
rachitis, and angiosclerosis. A predisposition to 
cataract is also not infrequentlv inherited, an unusual 



DISEASES OF THE CRYSTALLINE LENS. 303 

number of cataracts being observed in successive 
generations of certain families. 

The diseases of the eye most apt to lead to opacity 
of the lens are those which involve the uveal coat — the 
iris, ciliary body, and choroid. Cataract is also a usual 
consequence of unchecked inflammatory glaucoma. 
Lifelong accommodative strain, due to uncorrected 
refractive errors, through the congestion and inflamma- 
tion which it induces in the inner tunics of the eye, is, I 
am persuaded, a far from uncommon cause of cataract. 
The frequency with which I have observed, especially 
in astigmatic eyes, incipient cataract associated with 
miliary choroido-retinitis, or with evidences of pre- 
existent choroido-retinitis of this type, long since forced 
this conviction upon me. 

Traumatic cataract is usually the result of injuries 
which involve the capsule of the lens, such as penetrat- 
ing wounds of the cornea and lens, or of the cornea, iris, 
and lens. When a rent is made in the capsule, opacifi- 
cation of the entire lens commonly follows in a short time, 
in consequence of the action of the aqueous humor upon 
the lens substance. In rare instances, when the wound 
in the capsule is small it may close, and there may result 
only a circumscribed and stationary opacity, which, 
unless centrally located, may cause little or no impair- 
ment of vision. Usually when injured the lens swells 
considerably, and the pressure which it then exerts 
upon the iris and ciliary body may excite inflam- 
mation of these structures; secondary glaucoma may 
also be brought about in this way. Severe concussion 
of the eyeball, even when unattended by rupture of the 
lens capsule, is at times followed by the development 
of cataract. 

Congenital cataract, which is almost invariably binoc- 



304 PREVALENT DISEASES OF THE EYE. 

ular, is caused by disturbed nutrition or inflammation 
of the eye in intrauterine life. An inherited predispo- 
sition to this variety of cataract is especially common. 

To the general practitioner the most important matter 
with reference to cataract is its diagnosis, the ability to 
recognize its existence, and to determine the stage of its 
development; for, unquestionably, the operative treat- 
ment of cataract should not be undertaken except by 
those who have had special training in this branch 
of surgery. The physician who is able to diagnosticate 
cataract in its early stages, and hence to give a correct 
prognosis as to the impending loss of sight, deserves, 
and will receive, no little credit; and if, further, he is 
qualified to decide as to its maturity — whether or not it 
has reached the stage when an operation should be 
performed — he is in a position to give to his patient 
advice of much value. 

As a rule, when a cataract has progressed far enough 
to appreciably impair sight its recognition is not a 
matter of great difficulty, even to the non-specialist. 
This observation, as has been intimated, is especially 
true of cataract occurring in early life; but it is true also 
of senile cataract, if he will make use of the diagnostic 
aids which are within his reach. 

To begin with, familiarity in the employment of 
"oblique illumination," which, as explained in the 
chapter upon " diagnosis," is not difficult of acquire- 
ment, will enable him to distinguish with certainty 
between lenticular and corneal opacities, between opac- 
ities situated behind and in front of the plane of the iris. 
It will enable him also to detect slight opacities in the 
lens, in its anterior portion especially, which might 
otherwise escape observation. Again, the use of an 
evanescent mydriatic (a one per cent, solution of horn- 



PLATE VII 




Fig. 



Fig. 





Fig. 3. 



Fig. 4. 



Fig. 1. — Mature cataract, as seen by daylight or bv oblique illumination 
(after Sichel). 

Fig. 2. — Immature cataract, as seen by transmitted light (with ophthal- 
moscope or ear-mirror). 

Fig. 3. — Zonular cataract, as seen, with pupil dilated, by oblique illu- 
mination (modified after Sichel). 

Fig. 4. — Zonular cataract, as seen with ophthalmoscope or ear-mirror, 
(pupil dilated by atropin) (after Jaeger). 



DISEASES OF THE CRYSTALLINE LENS. 305 

atropin hydrobromate or a five per cent, solution of 
euphthalmin hydrochlorate), by exposing the lens more 
completely to inspection, will afford him further val- 
uable assistance. With a widely dilated pupil, and the 
aid of oblique illumination, only opacities situated in the 
periphery of the lens or near its posterior pole are likely 
to escape detection, and the former, as has been stated, 
are not apt to disturb vision (Plate VIII, Fig. i). 

The error into w T hich the general practitioner, even 
with these aids, is most apt to fall, is in mistaking the 
apparent opacity of the senile lens for true cataract. 
For, with the pupil dilated, and the light focused upon 
the exposed lens, the yellowish color and the seeming 
opacity of the nucleus common in the aged are made 
especially conspicuous, so that the expert even may be 
inclined to believe that a cataract is present. Any 
doubts that he may entertain upon this point, however, 
are soon dispelled by the use of the ophthalmoscope, 
since by transmitted light the apparent opacity, made 
conspicuous by oblique illumination, disappears, and 
only such opacity as is real, as constitutes cataract, is 
seen. Real opacities observed in this way, the ophthal- 
moscopic mirror being held about twelve inches from 
the eye, no longer appear gray or yellowish, as they do 
by focused light, but, if the cataract is incomplete, are 
seen as blackish spokes or flocculi, or as a dark central 
area, against the red background of the eye (Plate VIII, 
Fig. 2). 

This use of the ophthalmoscope does not require spe- 
cial training, so that those not skilled in ophthalmos- 
copy may make such an examination satisfactorily; 
and, if an ophthalmoscope be not at command, 
an ear or throat mirror will be found to answer 
almost as well, provided the light be placed at a 



306 PREVALENT DISEASES OF THE EYE. 

greater distance than usual from the eye under exam- 
ination, so that the illumination of the pupil shall not 
be too intense. In using such a mirror as a substitute 
for the ophthalmoscope, the observer must, of course, 
look through the opening in its center, otherwise the 
pupil will appear not red but black, and the lenticular 
opacities will not be seen. Ill-defined opacities limited 
to the periphery of the lens or situated at its posterior 
pole are comparatively difficult of detection even by 
transmitted light, and will hardly be recognized by 
those unfamiliar with the use of the ophthalmoscope. 

The steamy appearance of the lens, exaggerated by 
the mistiness of the cornea and vitreous humor, ob- 
served in inflammatory glaucoma might be mistaken 
for cataract; but, as the inflammatory symptoms, the 
high tension, etc., point unmistakably to the true con- 
dition, an error of this character is inexcusable. With 
more warrant, the opaque exudate occluding the pupil 
which is at times observed as a sequel of iritis may lead 
to a mistaken diagnosis of cataract. Inspection by 
oblique illumination, however, would show that the 
opacity was upon and not beneath the capsule, and the 
application of a mydriatic, by the failure of the pupil to 
respond or by its irregular dilatation, would in all prob- 
ability demonstrate the existence of posterior synechiae. 

The subjective symptoms of cataract, though not so 
pathognomonic as the objective signs, are nevertheless 
of diagnostic value. Mention has already been made 
of one of the most characteristic premonitory symptoms 
— the acquisition of " second sight." It should be 
remarked, however, that though this symptom indicates 
very clearly what is impending, it may, in exceptional 
instances, antedate by many months the development 
of such an amount of lenticular opacity as will seriously 



DISEASES OF THE CRYSTALLINE LENS. 307 

impair vision. The slowly progressive failure of sight, 
unattended by inflammatory symptoms, observed in 
cataract is not, in itself, characteristic, for we meet with 
this in other conditions, such, for example, as progres- 
sive atrophy of the optic nerve; but when it occurs 
without loss or diminution of pupillary reaction to light, 
the presumption is very strong that it is due to advanc- 
ing lenticular opacity. Monocular diplopia or polyopia, 
most apt to be observed in regarding a bright light or 
a brilliantly illuminated object, such as the moon, is 
another symptom strongly suggestive of cataract, since 
it rarely occurs except in consequence of incomplete 
opacity of the lens, which causes the light in its passage 
toward the retina to be broken up into separate pen- 
cils. Better vision in subdued light, as after the setting 
of the sun, is another suggestive symptom, often men- 
tioned by patients with incipient cataract, and which 
has its explanation in the increased size of the 
pupil under such circumstances. In line with this is 
the improvement in vision which often results in 
partially developed cataract from the application of a 
mydriatic. 

Finally, it is to be stated, cataract should be suspected, 
and should be carefully searched for, whenever there is 
failure of sight, without other evident cause, in persons 
who have reached or who have passed middle age, 
in individuals known to be suffering with diabetes, and 
in infants or children with congenitally defective 
vision. 

The determination of the maturity or " ripeness'' 
of cataract is not so simple a matter as we were formerly 
taught to believe. Not very many years ago, a cataract 
was held to be mature if with the affected eye there was 
inability to count fingers, while it was regarded as imma- 



308 PREVALENT DISEASES OF THE EYE. 

ture if this amount of vision was present. This "rule 
of thumb" is now known to be subject to so many excep- 
tions that it can no longer be regarded as a trustworthy 
guide. Before speaking of these exceptions, it will be 
well to consider what is meant by a mature or ripe 
cataract. 

A surgically mature cataract is one that is in a favor- 
able condition for operation — one that may be easily 
and completely removed. In other words, it is a cat- 
aract in which all of the lens fibers have undergone de- 
generation, and in which, as one of the consequences 
of this change, the intimate connection that normally 
exists between the lens proper and its capsule has been 
lost. Such a cataract has been aptly compared to a 
ripe fruit, which may be readily removed from its rind. 
Now, it is a fact that there does not exist a constant rela- 
tion between this condition and the degree of impair- 
ment of sight. That is to say, there are immature 
cataracts which reduce vision to mere light perception, 
while, on the other hand, there are mature cataracts, 
cataracts in a thoroughly satisfactory condition for oper- 
ation, which impair sight much less markedly, not 
only ability to count fingers at several feet, but to 
distinguish large letters at this distance with no great 
difficulty, being retained. It is evident, therefore, that 
there are other factors, besides the amount of sight im- 
pairment, which must be taken into account in deter- 
mining the surgical maturity of a cataract. The 
important point is to know how completely the lens 
has undergone degeneration. 

If when inspected by oblique illumination portions 
of the lens are seen to be still transparent, the cataract 
is manifestly immature, the degeneration of the lens 
fibers is incomplete. The flocculent, glistening, mother- 



DISEASES OF THE CRYSTALLINE LENS. 309 

of-pearl appearance frequently seen in senile cataracts 
especially, and due to a lack of uniformity in the degen- 
eration of the lens substance, is another evidence of 
immaturity, although when this condition is present 
vision is seldom better than light perception. 

The cataracts which, notwithstanding their maturity, 
permit such a considerable degree of vision as has been 
described (ability to count fingers, etc.) are commonly 
observed in persons who are well advanced in years — 
over sixty-five or seventy years of age — and in whom, 
therefore, the nucleus of the lens is relatively large and 
the overlying layer of cortical substance comparatively 
thin. The most striking examples of cataract of this 
character are those which exhibit a decidedly yellowish 
or amber color. It is the large size and the comparative 
clearness of the nucleus in such cataracts that explains 
the relatively good vision retained, and also the fact that 
not infrequently when the ophthalmoscope is used a 
sufficient amount of light reaches, and is reflected from, 
the fundus of the eye to give a reddish pupillary reflex, 
a thing which is never observed in the unripe, mother-of- 
pearl cataract or in even the far from mature juvenile 
cataract. 

Almost without exception these amber-colored, seem- 
ingly unripe, cataracts prove to be in an ideal 
state for operation; that is, they are easily extruded 
from the capsule, and if any bits of the cortical sub- 
stance are left behind they are dissolved speedily and 
soon disappear, because they have undergone pre- 
viously such complete degeneration. In this respect 
they behave entirely unlike the clear lens substance of 
an immature cataract when left in situ, which increases 
in bulk as it becomes opaque, resists absorption for a 
considerable time, is apt to excite inflammation of the 



310 PREVALENT DISEASES OF THE EYE. 

iris, and may in this way lead to the formation of a sec- 
ondary cataract. 

Treatment. — An important point to be impressed upon 
the general practitioner with regard to the treatment of 
cataract is that the only effectual method of dealing with 
the condition is by operation. One frequently hears 
of the claims put forth by charlatans that they can cure 
cataract, that they can dissipate lenticular opacities, by 
means other than operative; but, without exception, 
these claims, when subjected to investigation, have 
proved to be entirely without justification, to be, in fact, 
purely fraudulent. 

In the incipient stage of cataract, when the opacity 
is confined to the periphery of the lens, if the ophthal- 
moscope affords evidence to warrant the belief that the 
lenticular changes are dependent upon a low grade of 
choroido-retinitis, it is proper to take measures to com- 
bat this latter condition; for, if this can be done success- 
fully, there is ground for hope that the develop- 
ment of the cataract may be arrested or, at least, re- 
tarded. The most effectual means of doing this consist 
in the careful correction of any refractive errors that 
may be found to be present; in moderation in the use 
of the eyes; in inducing by suitable measures regular 
action of the bowels, and in the administration of small 
doses of biniodid of mercury (gr. -$-$ to -3V) or of po- 
tassium iodid. If, however, the opacity has advanced 
so far as materially to impair sight, such measures will 
be without avail. 

During the stage of immaturity, while the cataract 
perhaps is developing slowly, temporary but greatly 
appreciated improvement in vision may be obtained, in 
some instances, by keeping the pupil moderately dilated 
through the application of a mydriatic. The cases 



DISEASES OF THE CRYSTALLINE LENS. 3II 

in which this is possible are those in which the opacity 
is limited to the central portion of the lens or, at least, 
is more dense there than it is in those parts of the lens 
that are commonly covered by the iris. A weak solution 
of atropin (gr. J togi) is best adapted to this purpose, 
and need not be applied, as a rule, oftener than once 
in three or four days. A single application will suffice 
to determine whether or not this will prove helpful. 
In using so weak a solution of atropin there is little dan- 
ger, even in the aged, of causing an abnormal increase 
of intraocular tension; but the possibility of this should 
be borne in mind, and should any evidences of an in- 
duced glaucoma be observed, the mydriatic action of 
the atropin must be neutralized at once by the use of 
eserin. 

It may be well to add that one should take 
care that the temporary improvement in the patient's 
vision caused by the mydriasis does not lead him to 
entertain false hopes that he is being cured. It is a 
common practice with quacks to employ a mydriatic 
in incipient cataract for this very purpose, and it is not 
difficult for them to persuade their dupes that an agent 
which, as the result of a single application, has made 
so marked an improvement in vision will in a short 
time effect a complete cure. 

Another practical suggestion, having to do with the 
incipient stage of cataract, is as to the unwisdom of 
telling the average patient that a cataract is beginning 
to develop in his eye, which will in time lead to loss of 
sight. Months may elapse, in some instances even 
years, after the ophthalmoscope has revealed the pres- 
ence of slight peripheral opacity of the lens before a con- 
siderable impairment of vision occurs, and during all 
this time the individual may be relieved of the dread of 



312 PREVALENT DISEASES OF THE EYE. 

impending blindness, and the unhappiness to which this 
is sure to give rise, if the information gained by our in- 
spection of the eye be kept from him. It is a case to 
which the proverb, "where ignorance is bliss," etc., 
is strikingly applicable. It is proper, however, for 
our own protection, if for no other reason, that some 
member of the patient's family should be made aware 
of the true condition. On the other hand, if the sight 
is already decidedly impaired it is best to tell the patient 
frankly what the trouble is, since we are then in a posi- 
tion to give him a very favorable prognosis, and so 
relieve his mind of much anxiety. 

The question often arises as to the advisability of 
operating for cataract upon one eye, when the sight of 
the fellow-eye is as yet unimpaired. It may be stated, 
as a general truth, that the improvement in vision gained 
by doing this will not be very considerable; for 
the unaffected eye will still be used for all accurate 
seeing. The field of vision, however, will be widened, 
and there are certain other advantages to be gained 
which deserve consideration. In the first place, if the 
patient is still young, the improvement in personal ap- 
pearance resulting from the removal of so serious a 
blemish as is caused by the presence of a monocular 
caratact is a matter not always to be ignored. Again, 
and this applies more particularly to cases in which there 
are incipient evidences of the formation of a cataract 
in the fellow-eye, it is a great comfort to the patient to 
feel that one eye has been operated upon successfully, 
and that he will have this eye to fall back upon when 
the sight of the other finally fails. Still another con- 
sideration is that cataracts in time, after having passed 
through the stage of maturity, tend to become overripe, 
or hypermature, in which condition, owing to the tough- 



DISEASES OF THE CRYSTALLINE LENS. 313 

ening of the capsule and the secondary degenerative 
changes in the lens, they are in a less favorable state 
for operation. 

On the whole, taking into consideration the 
infrequency at the present day of unfavorable re- 
sults in operations for cataract, it is best, I think, 
if there is evidence of beginning lenticular opacity in 
the relatively good eye, to operate upon the other eye, 
provided the cataract is fully mature. On the other 
hand, if it is immature, the operation should be 
deferred, at least until the sight of the better eye has 
become appreciably impaired. And here it may be 
remarked that when, as frequently happens, the lens 
opacity develops concurrently in the two eyes, so that 
the sight of each is much impaired, there is a disposition 
at the present day, more especially in dealing with 
persons who have reached the age of sixty-five or 
seventy, to operate upon the eye in which the opacity 
may be more advanced, without waiting for the 
cataract to become fully mature, the reason for this 
being that in the aged the nucleus of the lens is so 
large and the cortical substance so inconsiderable in 
amount that, even when it has not undergone 
complete degeneration, it is not apt to give rise to 
complications. 

In persons under the age mentioned, if the sight of 
each eye is much affected, and the cataract in each is 
still immature, the procedure of Fbrster is indicated. 
This consists in the performance upon one eye of a 
preliminary iridectomy, accompanied by a bruising 
or "trituration" of the lens. The purpose of this 
procedure is to hasten the ripening of the cataract, so 
that its removal may be undertaken sooner than other- 
wise would be practicable. The desired result is not 



314 PREVALENT DISEASES OF THE EYE. 

always secured; but not infrequently, within five or six 
weeks of the performance of the operation, the cataract 
will have reached a state of maturity which it might not 
have reached in many months had it been left to ripen 
in the usual way. 

Although the operation of cataract extraction was 
known to the Romans of the period of the Empire, 
and was practised during the middle ages by the Arab- 
ians, it was not revived in Europe until the middle of 
the eighteenth century; and long after that, indeed as 
late as the middle of the last century, the real indications 
for its performance in preference to the more easily 
executed operations of couching or depression and of 
discission were but imperfectly understood. At the 
present day the manner in which a cataract shall be 
operated upon — whether it shall be "needled" and 
allowed to undergo solution in the eye or shall be ex- 
tracted from the eye — is determined by its consistency, 
by its hardness or softness, that is to say, by whether 
it contains or does not contain a firm nucleus. Hence 
it is that all senile cataracts, indeed, all cataracts occur- 
ring in persons over thirty years of age, are extracted; 
while all juvenile cataracts are needled. 

Formerly, in the operation of discission, as well as in 
that of couching, the cataract needle was introduced 
through the sclera, and the lens was attacked from 
behind. In the modern operation of discission, on the 
contrary, the needle is always introduced through the 
cornea, and the lens is attacked through the anterior cap- 
sule, in which a more or less extensive rent is made. The 
purpose of this is to expose the cataract to the action 
of the aqueous humor, which in time effects its solution 
and absorption. This process is a slow one, and com- 
monly consumes several months, and not infrequently 



DISEASES OF THE CRYSTALLINE LENS. 315 

more than one needling is required. It is, however, 
a much safer procedure, especially in infants and 
children, than the operation of extraction, and is less 
liable to accidental or other complications. At the 
time of the operation the pupil must be widely dilated 
by atropin, and this dilatation must be maintained until 
the absorption of the lens is complete. Under the in- 
fluence of cocain the operation is painless; but in young 
children it is best usually to employ a general anes- 
thetic, the primary anesthesia induced by chloroform 
being sufficient, as the needling requires but a few 
moments. Unless complications occur there is little 
or no after-suffering, and, except for a few days, the 
patient need be subjected to but slight restraint. 

There are two methods of operating upon hard, or 
senile, cataracts in vogue at the present day — simple 
extraction and combined extraction, or extraction with 
iridectomy. Each has its advocates, though the latter 
procedure, because less liable to unpleasant com- 
plications, is probably more than holding its own. 
For myself, as the result of a considerable experience 
with both methods, I have come to prefer combined 
extraction, and for some years have operated by this 
method only. 

With the eye thoroughly cocainized, the operation 
of cataract extraction, whichever procedure be em- 
ployed, is seldom attended by pain that is at all intoler- 
able, and frequently is entirely painless. The making 
of the corneal section is hardly ever painful, for the 
cornea is thoroughly anesthetized; but as the anesthesia 
of the iris is usually less complete, it is not uncommon 
for some pain to be experienced when it is drawn out 
and cut in the combined operation, or compressed and 
stretched in the extrusion of the lens in simple extrac- 



3l6 PREVALENT DISEASES OF THE EYE. 

tion. Some discomfort in the eye, at times amounting 
to pain, is often felt during the twelve hours following 
the operation; but, if no complications occur, this usu- 
ally constitutes the sum of the patient's suffering. For 
three days it is best that he should be kept in bed, with 
both eyes closed; but on the fourth he may sit up and 
have the use of the unoperated eye. At the end of a 
week the dressings are left off the other eye, and usually 
at the end of two weeks he is able to leave the hos- 
pital, being provided with a pair of smoke-tinted glasses, 
to be worn until the eye is quite free from irritation and 
in a favorable condition for the adjustment of the "cat- 
aract glass," which, of course, is essential to clear 
vision, and which, thenceforth, he will wear contin- 
uously. 

As to the chances of an operation for senile cataract 
being successful, it may be said that with the great 
help afforded by cocain, with the means at command 
for lessening the likelihood of post-operative accidents 
(Fig. 122), and with the careful antiseptic precautions 
employed at the present day the percentage of failures 
in the hands of experienced operators is extremely 
small — scarcely more than four per cent. In spite 
of every precaution, about two per cent, of the eyes 
operated upon are lost by infection, the infection 
in some instances doubtless being entogenous. The 
other two per cent, of failures is usually attributable 
to unruly behavior upon the part of the patient, either 
during or after the operation, to the existence of other 
disease of the eye apart from the cataract, or to some 
misadventure in the performance of the operation. 

In one hundred consecutive cases of cataract extrac- 
tion reported by the author a few years since* the opera- 

* "American Journal of Ophthalmology," Dec, 1899. 



DISEASES OF THE CRYSTALLINE LENS, 



3 l 7 



tion was successful in ninety cases, the vision obtained 
varying from 2 c ° to 4|, and partially successful, vision 
being less than 2 ° c , in six cases, while two eyes were lost 
from infection, and in two others no improvement in 
vision resulted, though recovery from the operation was 
smooth, owing to pre-existent disease of the retina. 




Fig. 122. — Dr. Murdoch's protective shield as applied after cataract ex- 
traction. The left eve is closed with a pad of gauze and absorbent cotton — 
a convenient dressing in less delicate operations. 



In ninety-three operations performed since this report 
there have been four failures, two from suppuration — 
exactly the same as in the first series — and two from 
other causes, a percentage of failures for the whole series 
of nearly two hundred cases of slightly less than 3.1 1. 
Among the conditions which militate against the 
success of the operation of extraction of cataract may 



318 PREVALENT DISEASES OF THE EYE. 

be mentioned the existence of diabetes. This should 
not be regarded as a contraindication to its perform- 
ance, however, as in the great majority of such cases 
the operation proves successful. The presence of an 
arcus senilis was formerly regarded as influencing the 
prognosis unfavorably, but this is now known not to be 
the case. There is, moreover, little ground for the 
popular belief that advanced age lessens materially 
the chances of success of an operation for cataract. 
One often hears of persons who hesitate to submit to 
operation because they fear, or have been told, that they 
are too old to undergo it. My own experience is, and 
it agrees with that of other ophthalmic surgeons, that 
cataract operations upon octogenarians, if for their age 
they are in fairly good health, are as apt to be successful 
as are those performed upon persons who have not yet 
reached the biblical threescore years and ten. 

Another popular misapprehension is as to the likeli- 
hood of a cataract returning after it has been removed. 
"If I have my eye operated upon, can I feel any assur- 
ance that the cataract will not return ?" is the way it is 
often put. Once removed, a cataract, strictly speaking, 
never returns; but capsular opacities, sometimes spoken 
of as secondary cataracts, occasionally develop even 
after the most successful operations, and may interfere 
with vision to such a degree as to require "needling." 
And in this circumstance, doubtless, is to be found the 
explanation of the misconception in question. 

Not only do senile cataracts require to be extracted, 
but, under certain circumstances, soft, or juvenile, cata- 
racts as well must be dealt with in this way. For ex- 
ample, a traumatic cataract occurring in a young person 
may become so swollen, and the anterior chamber so 
filled with opaque lens substance, as to cause much irrita- 



DISEASES OF THE CRYSTALLINE LENS. 3 10, 

tion, and, perhaps, induce a glaucomatous condition; 
and a similar state of affairs may follow the operation 
of discission performed upon a soft cataract. Under 
such circumstances, the partial or complete removal 
of the cataract is called for, and this is accomplished 
by a linear extraction or by what is known as suction 
extraction. In the one case a linear incision, about 5 
mm. in length, is made in the cornea, a little in front 
of the plane of the iris, and the lens substance is coaxed 
out by carefully exerted pressure and counter-pressure. 
In the other, a similar incision is made, and the nozzle 
of a suction syringe, especially adapted to the purpose, 
is introduced into the anterior chamber, and the semi- 
fluid cataractous substance is cautiously sucked out. 
Successfully carried out, these procedures not only 
relieve the irritation and reduce the tension of the eve, 
but greatly hasten the restoration of vision, for which 
purpose alone they are sometimes employed. 

It is well to remember, in dealing with congenital 
cataracts, that it is not safe to postpone operating too 
long after birth, since in the new-born permanent 
amblyopia is apt to result from nonexercise of the retina. 
In adults there is no risk of this sort. 

In all operations for cataract a rule which I have in- 
variably adhered to, and which I think should never 
be departed from, is to operate upon only one eye at a 
time. For, should the first operation not prove success- 
ful, the experience gained with this eve may be very 
helpful when we come to deal with the other eve. 
Again, an intercurrent infection may involve both eves, 
or the failure of the operation upon one eve may lead 
to complications in the fellow-eve. In a word, as the 
homely proverb has it, we should never put all our eggs 
in one basket. 



320 PREVALENT DISEASES OF THE EYE. 

Exceptionally, after excellent sight resulting from a 
cataract operation has been enjoyed for months, a grad- 
ual decline in vision may occur. This is due usually 
to a wrinkling of the posterior half of the lens capsule, 
and if the disturbance of vision is considerable a needle 
operation is called for; that is, a central rent should be 
torn in the capsule with a cataract needle or needle- 
knife. This operation, under cocain anesthesia, is not 
painful, but it demands rigid antiseptic precautions; the 
outcome is commonly most satisfactory. 

Partial Cataract. — Partial cataracts, which fre- 
quently are of congenital origin, differ from general 
cataracts, as has been said, in that they show little or no 
disposition to involve the whole lens, the opacity usually 
remaining circumscribed and stationary throughout 
life. There are several varieties of partial cataract, 
which differ radically as to their appearance, as to their 
etiology, and as to their effect upon vision. In two of 
these the opacity is limited to the anterior pole of the 
lens. These, therefore, are denominated anterior polar 
cataracts. There are also two varieties in which the 
opacity is confined to the posterior pole of the lens, and 
which are known as posterior polar cataracts. Finally, 
there is the variety known as zonular, or lamellar, cata- 
ract, in which there is, within the lens, a hollow, oblate 
sphere of opacity, which encloses, and is surrounded by, 
clear lens substance. 

Anterior Polar Cataract. — Of the two varieties of 
anterior polar cataract the one less frequently en- 
countered is due to the persistence of a portion of the 
embryonic pupillary membrane, which has adhered to 
the lens capsule and undergone calcification. A cir- 
cumscribed, densely white opacity, occupying a limited 
portion of the pupillary area, and evidently lying upon, 



DISEASES OF THE CRYSTALLINE LENS. 32 I 

and not within, the capsule, is observed. Vision is not 
necessarily greatlv disturbed. 

The other variety of anterior polar cataract, known 
also as pyramidal cataract, occasionally develops during 
intrauterine life, but is commonly of postnatal origin, 
and has its starting-point in a central, perforating ulcer 
of the cornea, usually consequent upon ophthalmia neo- 
natorum (Fig. 123). When a perforation of the cornea 
occurs, the aqueous humor escapes, the anterior chamber 
is obliterated, and the iris and lens are pressed forward 
so that they lie in contact with the cornea, where they 
remain until the anterior chamber is restored. When 



- 







Fig. 123. — Anterior polar cataract (after Xettleship). 

the perforation is so situated that the lens lies in direct 
contact with it, an irritation results which leads to 
proliferation of the subcapsular epithelial cells. The 
outcome of this is the formation, just beneath the an- 
terior capsule, of a sort of fibrous tissue, which is white 
and opaque, and persists throughout life (Fig. 124). In 
addition to this, there is frequently a projecting mass of 
opaque material upon the external surfaceof the capsule, 
at a point corresponding with the intracapsular opacity. 
This consists of an organized exudate which remains 
adherent to the capsule when, in consequence of the 
re-accumulation of the aqueous humor, the lens is 



322 



PREVALENT DISEASES OF THE EYE. 



pushed away from the cornea. The pyramidal shape 
of this opacity is evidently the result of the traction to 
which it is subjected when the lens and cornea are thus 
forced apart. A perceptible corneal opacity usually 
marks the site where the ulcer perforated, and in some 
instances there may be seen a slender band of opaque 
tissue connecting this opacity with the apex of the 
epicapsular exudate. The degree of visual disturbance 
in pyramidal cataract depends largely upon the size of 




Fig. 124. — Section of anterior polar cataract. Magnified 40 X 1 (Fuchs). 
The capsular cataract forms a projection upon the anterior surface of the lens, 
covered by the capsule, k, which is unchanged and simply thrown into folds. 
The capsular epithelium, e, loses its regularity at the border of the cataract, 
its cells being increased in number and separated by the cataract from the 
capsule, so as to form for a short distance the posterior boundary of the cat- 
aract. The cataract consists of a fibrous tissue, with cells lying in the 
spindle-shaped gaps between the fibers. Succeeding the cataract posteriorly 
is liquor morgagni, M, which is coagulated into a pulverulent mass, separat- 
ing the capsule from the cataractous layers of the lenticular cortex (which 
are not represented in the illustration). 

the opacity relatively to that of the pupil, and upon its 
sharpness of definition. A dense opacity, if small and 
defined, is not incompatible with good vision. The 
corneal scar, though much less conspicuous, may pro- 
duce far greater disturbance of sight. 

Posterior Polar Cataract. — Opacities at the posterior 
pole of the lens, which are apt to cause greater impair- 
ment of vision than thoseat the anterior pole, can seldom 
be detected without the aid of the ophthalmoscope, 



DISEASES OF THE CRYSTALLINE LENS. 



323 



though in some instances, with a widely dilated pupil, 
they may be fairly well seen by oblique illumination. 
Observed in this way, they are rather ill-defined and 
of a yellowish-gray color, whereas with the ophthalmo- 
scope they appear black against the red background 
of the eye. 

In the commoner form of posterior polar cataract the 
opacity, which may lie either just in front of the capsule 
or between it and the hyaloid fossa, is usually diffuse 
and ill-defined, sometimes exhibiting an imperfect star- 





Fig. 125. — Posterior polar cat- 
aract as seen by transmitted light 
(from a case of pigmentary degen- 
eration of the retina) (Hopkins). 



Fig. 126. — Cross-section of zonu- 
lar cataract. Schematic. Magni- 
fied 2X1 (Fuchs). The layers, s, 
lying between nucleus and cortex, 
are opaque, but the adjacent layer is 
so only in the equatorial region, r, 
indicating the presence of "riders." 



shape (Fig. 125). This variety is commonly due to pre- 
existent disease of the deeper tunics of the eye, which has 
interfered with the normal nutrition of the lens. Ret- 
initis pigmentosa, diffuse choroido-retinitis, and myopia 
of high grade, attended by marked choroido-retinal 
changes, are the conditions most apt to give rise to it. 
The impairment of vision is apt to be considerable, 
and there is a greater probability than in any other form 
of partial cataract that the opacity may eventually 
involve the whole lens. 



324 PREVALENT DISEASES OF THE EYE. 

The other, and rarer, form of posterior polar cataract 
is of congenital origin, and is due to the incomplete 
disappearance of the remains of the hyaloid artery, 
which in fetal life runs forward in the vitreous humor 
to the posterior pole of the lens. The opacity, which 
is upon, not within, the capsule, is small and defined, 
and seldom produces an appreciable disturbance of 
sight. Occasionally remnants of the hyaloid artery 
may be traced from the epicapsular opacity to the 
optic disc. 

Zonular, or Lamellar, Cataract. — This is, perhaps, 
the most peculiar and interesting variety of partial cat- 
aract. The zone of opacity, which has been described 
(Fig. 126), varies considerably in size and also in thick- 
ness. Exceptionally there may be more than one 
opaque zone, the smaller zone being within the larger, 
and separated from it by a layer of transparent lens sub- 
stance. Under such circumstances there is first a zone 
of clear lens next to the capsule, then an opaque zone, 
then another clear zone, and within this a second opaque 
zone enclosing a transparent nucleus. 

This singular form of lens opacity, which nearly 
always affects both eyes, and a disposition to which is 
not infrequently inherited, develops either during the 
last months of fetal life or in early infancy, never in 
adult life. It is often found in association with inher- 
ited syphilis, rickets, or scrofula, and the majority of 
individuals in whom it occurs have suffered with infan- 
tile convulsions. Though its etiology is but imperfectly 
understood, it is probable that the explanation of its de- 
velopment is to be found in faulty nutrition, perhaps of 
intermittent degrees of intensity. Its frequent associa- 
tion with rachitic teeth is interesting, and helps to 
throw some light upon the way in which it is produced. 



DISEASES OF THE CRYSTALLINE LENS. 325 

There is commonly marked impairment of sight, 
though not so marked as in advanced general cataract. 
The amount of visual disturbance depends upon the 
thickness and density of the opaque zone, and there are 
cases in which this thickness and density are so slight 
as to interfere but little with vision. In most instances 
the opacitv remains stationary, and retains its pecul- 
iaritv, throughout life, though exceptionally the whole 
lens ultimately may become opaque. 

The true character of zonular cataract seldom can 
be recognized until the pupil has been dilated by a 
mydriatic; for before this is done it presents much the 
appearance of an ordinary, immature cortical cataract. 
With the pupil widely dilated, however, the clear per- 
ipheral zone enclosing the smaller opaque zone may 
be made out easily by oblique illumination or with the 
ophthalmoscope or, as has been suggested, when an 
ophthalmoscope is not available, with the ordinary ear 
or throat mirror (Plate VIII, Figs. 3 and 4). 

Treatment of Partial Cataract. — In anterior polar 
cataract, unless the vision is decidedly impaired, no 
treatment is indicated. If, however, the opacity is so 
considerable in extent as to occupy the greater part of 
the pupillary area, an iridectomy, made with the view 
of obtaining an artificial pupil opposite a clear portion 
of the lens, may be of decided benefit. The instillation 
of a mydriatic will indicate to what extent vision is 
likely to be improved by this procedure. 

In posterior polar cataract an iridectomy is apt to 
be of little utility, and, as a rule, operative treatment is 
not indicated. When, however, the sight of both eyes 
is markedly impaired an endeavor to cause the whole 
lens to become opaque, by Forster's method or possibly 
by cautious needling, with a view to its subsequent re- 



326 PREVALENT DISEASES OF THE EYE. 

moval, is justifiable. When the opacity is consequent 
upon choroido-retinitis, treatment of the latter condition 
is called for, and mav be of some avail. 

Zonular cataract, if it causes, as it usually does, 
marked impairment of sight, should be dealt with in 
one of two ways — either an artificial pupil should be 
made opposite the clear portion of the lens or discission 
should be performed. The former procedure is indi- 
cated when the cloudv zone is small and the clear zone 
relatively broad and free from the opaque spokes 
("riders,'*' as thev have been called) which not infre- 
quently are present, and when, moreover, dilatation ol 
the pupil bv a mydriatic is found to produce decided 
improvement in vision. Discission is called for when 
the opposite conditions exist, that is, when the opaque 
zone is wide, the clear zone narrow, when there are many 
and conspicuous "riders," and when inconsiderable im- 
provement in sight results from mydriasis. The process 
of absorption ot the lens through needling is a slow one 
in zonular cataract because so much of the lens is clear, 
and the breaking down of its fibers, which must precede 
their solution and absorption, takes a long time; but the 
ultimate result is apt to be more satisfactory than when 
an artificial pupil is made. After the lens has been ab- 
sorbed a cataract glass must, of course, be worn. 

Secondary, or Capsular, Cataract. — After operations 
upon the lens and after injuries involving the integrity of 
its capsule it mav happen that some of the lens substance 
becomes imprisoned within the capsule in such a man- 
ner as to resist absorption. It mav also happen that 
inflammatory exudates are deposited upon or within 
the torn capsule. In either case a more or less pro- 
nounced opacity, occupying the pupillary area and ser- 
iously interfering with vision, mav result. Such opaci- 



DISEASES OF THE CRYSTALLINE LENS. J2J 

ties are called secondary or capsular cataracts, and, if 
the disturbance of vision which thev cause is consider- 
able, must be dealt with bv operative procedure. 

Capsular cataracts are often so conspicuous that 
thev may be detected at a glance; but thev can be ex- 
amined best, and their extent and character determined 
most satisfactorily, bv oblique illumination, after the 
pupil has been widelv dilated bv a mydriatic. 

Treatment. — This consists in making- a rent in the 
opaque membrane — in its center, if possible — so that 
a clear area may be secured through which light can 
pass, unobstructed, to the retina. Exceptionally, it 
mav be necessary to deal with these secondary opacities 
in a more radical way; but usually the desired result 
mav be attained bv a discission operation, that is, bv 
introducing a cataract needle or needle-knife into the 
anterior chamber through the cornea, near its periphery, 
and cutting or tearing (for it is oftener a tear rather than 
a cut, the authorities to the contrary, notwithstanding") 
an opening in the opaque membrane. If the membrane 
is thick, it is best to divide it crucially; but when, as is 
often the case, it is cobweb-like in character, a linear 
incision suffices, as the elasticity of the capsule causes 
the rent to expand sufficiently for the end in view. The 
operation is done under cocain, with the strictest anti- 
septic precautions, and with the pupil dilated ad max- 
imum. 

Dislocation of the Crystalline Lens (Luxation of 
the Lens). — Dislocation of the crystalline lens, which 
occurs as a congenital as well as an acquired condition, 
mav be complete or incomplete, and the displacement 
mav be forward, into the anterior chamber, or back- 
ward, into the vitreous chamber. The lens is said to be 
incompletely dislocated when it remains in the hyaloid 



328 PREVALENT DISEASES OF THE EYE. 

fossa, held measurably in place by remnants of the 
suspensory ligament or by the support of the vitreous 
humor. It is said to be completely dislocated when it 
has fallen back into the vitreous chamber or has passed 
through the pupil into the anterior chamber. 

Congenital dislocation of the lens, which is commonly 
bilateral (Fig. 127), and to which there is not infre- 
quently an inherited disposition, is usually incomplete, 
and is due to imperfect development or absence of the 
zonule of Zinn. Acquired dislocation is commonly the 
result of traumatism, though in certain conditions of the 





Fig. 127. — Congenital dislocation of the crystalline lenses, up and out (de 

Schweinitz). 



eye — myopia of high grade, especially, or after chronic 
inflammation of the uveal coat — a very trivial accident, 
an inconsiderable blow upon the eye, for example, may 
suffice to bring it about. Dislocation of the lens be- 
neath the conjunctiva (Fig. 128) is occasionally observed 
in severe injuries of the eye involving rupture of the 
sclera near the corneal border. 

Displacement of the lens from behind the pupil, un- 
less it happens to occur in a very myopic eye, necessarily 
causes marked impairment of vision. Moreover, by 
acting as a foreign body, the lens when loose in the 
vitreous chamber, and this is still more apt to happen 



DISEASES OF THE CRYSTALLINE LENS. 329 

when it is lodged in the anterior chamber, may cause 
great irritation, and excite severe inflammatory reac- 
tion. 

The disturbance of vision from a partially dislocated 
lens, if the margin of the lens happens to be in line 
with the pupil, is especially annoying; for under such 
circumstances two images are formed upon the ret- 
ina, a more distinct one by the rays of light which pass 
through the lens, and a less distinct one by those which 
reach the retina without passing through it, monocular 
diplopia being the result. A partially dislocated lens 
which lies behind the pupil in a tilted position — a con- 




Fig. 128. — Subconjunctival dislocation of lens (Haab). 

dition not infrequently observed — also causes marked 
impairment of sight, since it necessarily produces a 
high degree of astigmatism. 

A case of complete, probably congenital, dislocation 
of both lenses, exhibiting very unusual and interesting 
features, was observed, and an account of it published, 
by the author some years since * : In each eye of a lad, 
twelve years of age, the lens was completely dislocated 
into the vitreous chamber. In spite of this fact, and 

"Report of a case in which useful vision was maintained through 
a number of years by the aid of a totally dislocated lens." Trans, 
of the American Ophthalmological Society, 1881. With supple- 
mentary notes, as to the later history of the case, in the Transactions 
of the Society for 1891 and 1893. 



330 PREVALENT DISEASES OF THE EYE. 

though he had never had compensating glasses, he had 
attended school, had been able to keep up with his 
classes, and had been much given to reading for 
pleasure. 

In the course of my examination of the case it de- 
veloped that his ability to read was due to his having 
acquired the knack of using one of the dislocated lenses. 
Without, of course, appreciating the significance of the 
maneuver, he was in the habit, whenever he wanted to 
see any small object, as in reading, of bending his head 
forward, with face to the ground. This brought the 
lens into position behind the pupil (as I satisfied mvself 
bv observation with the ophthalmoscope), and in this 
awkward fashion he was able to read with ease the finest 
print. He was given far and near glasses, which greatlv 
improved his distant vision, and enabled him to read 
with his head in a natural position. Ten years sub- 
sequentlv, when he was twentv-two vears of age, the 
capsule of the lens in the left eve ruptured. This was 
followed bv considerable inflammatory reaction and 
decided impairment of vision. However, the lens grad- 
uallv underwent absorption, though a fragment of the 
nucleus proved verv obdurate, the inflammatory symp- 
toms subsided, and vision regained its former standard. 
Six years after this the same thing happened to the 
right eye, and for a time there was the same decided 
inflammatory reaction, which was not without difficulty 
gotten under control. 

Partial or complete dislocation of the lens backward 
is not alwavs easv of detection. A completelv dislo- 
cated lens — one that has fallen into the vitreous chamber 
— can be seen onlv with the help of the ophthalmoscope; 
a partially dislocated lens, after the pupil has been 
dilated by a mydriatic, may be satisfactorily inspected, 



DISEASES OF THE CRYSTALLINE LENS. 33 I 

and its position determined, by oblique illumination. 
A nearly constant symptom of backward dislocation of 
the lens is tremulousness of the iris — iridodonesis. 
This results from the iris having lost the support which 
the lens under normal conditions affords it. The exist- 
ence of this symptom, therefore, should always raise 
a suspicion that the lens is more or less completely 
luxated. 

When the lens lies in the anterior chamber (Fig. 129) 
the ease with which it may be detected by the non-expert 
depends largely upon whether it is transparent or catar- 




Fig. 129. — Dislocation of lens into anterior chamber (Hansell and Sweet). 

actous — for, it should be stated, dislocated lenses are 
very apt in time to become cataractous. An opaque 
lens in this situation should be detected at a glance, and 
the true state of affairs easily recognized. On the 
other hand, when the lens is clear it is not so easy as 
might be supposed to make a correct diagnosis. Oblique 
illumination would afford assistance, and a significant 
feature would be the unusual depth of the anterior 
chamber. In some instances a dislocated lens has a 
habit of gliding through the pupil, and being found now 
in front, and now behind, the iris. 

Treatment. — When a dislocated lens lies in the an- 



332 PREVALENT DISEASES OF THE EYE. 

terior chamber it is almost sure to give rise to much 
irritation, and to excite inflammation, it may be of a 
glaucomatous character. Its removal, therefore, is 
indicated. The operation is a delicate one, more so 
than an ordinary extraction of cataract, and should be 
undertaken only by one skilled in the performance of 
ophthalmic operations. 

A partially dislocated lens may or may not require 
radical treatment. If it causes but little impairment 
of sight it should be left undisturbed, glasses being given 
if found to be of assistance; but if it is so placed as to 
interfere seriously with vision it may be extracted or, 
perhaps, needled, the latter procedure being indicated 
only in young subjects. The extraction of a displaced 
lens which has not left the hyaloid fossa, and is supported 
by a vitreous humor of normal consistency, is hardly 
more difficult than the ordinary removal of a cataract. 

A lens completely dislocated into the vitreous cham- 
ber should not be disturbed, unless it is causing serious 
inflammatory reaction; for under such circumstances 
the vitreous humor is apt to be in a fluid or semifluid 
state, and an attempt to remove the lens is a hazardous 
procedure. It is possible, with the help of the ophthal- 
moscope, to needle a lens so situated, the needle being 
introduced through the sclera, and this procedure might 
be justifiable in a young person. Another possible pro- 
cedure is to coax the lens by suitable manipulation 
through a dilated pupil into the anterior chamber, and, 
after imprisoning it there by the use of a strong myotic, 
to extract it through a corneal section 

A lens dislocated beneath the conjunctiva may be 
extracted without difficulty. After the removal of a 
dislocated lens glasses, such as are prescribed a*fter an 
operation for cataract, are, of course, necessary. 



DISEASES OF THE VITREOUS Ill'MOK. 



333 



DISEASES OF THE VITREOUS HUMOR. 

Pathological changes in the vitreous humor seldom 
occur except as a result of traumatic lesions of the eye 
or in consequence of disease of the uveal coat or retina. 

Purulent Panophthalmitis. — The vitreous humor 
affords an excellent medium for the growth of bac- 
teria, and when a pyogenic organism finds lodgment 




IPs . 




Fig. 130. — Panophthalmitis, from entrance of a piece of iron into the vitreous 
chamber (HaarA 



there, as a result of a penetrating wound of the eye, 
operative or accidental, a destructive and usually uncon- 
trollable suppurative panophthalmitis is apt to ensue 
(Fig. 130). Under such circumstances, in a very brief 
time, purulent infiltration of the entire vitreous body 
occurs; the uveal coat and cornea are soon involved; 
and after much suffering, attended by marked chemosis 
of the conjunctiva and great tumefaction of the lids, 
necrosis of the cornea or of the sclera at some point 



334 PREVALENT DISEASES OF THE EYE. 

takes place. Then there is an escape of pus, with con- 
sequent reduction of the intraocular tension, and a 
measurable relief from pain is experienced. Complete 
loss of sight always results, and ultimately atrophy of 
the eyeball. 

Treatment. — So far as arrest of the suppurative pro- 
cess and preservation of sight are concerned, treatment 
is seldom of avail. Anodvnes are indicated to control 
the pain, and hot fomentations — the lotion of opium, 
made stronger than is commonly necessary (ext. opii, 
gr. xv ; aquae, oiv) — afford some relief. When it is 
evident that there is no hope of preserving sight, the 
eve should be enucleated without unnecessary delay. 
The danger of cerebral or systemic infection from the 
performance of the operation while the inflammation 
is still active seems to the author to have been much 
exaggerated, and the relief from suffering which it af- 
fords is almost instantaneous. 

Fluidity of the Vitreous Humor (Synchysis). 
— This condition usually results from chronic in- 
flammation of the uveal coat. It is, perhaps, often- 
est met with in myopia of high grade attended bv 
marked choroido-retinal changes. It is the outcome 
of malnutrition, and is frequently accompanied bv 
floating opacities. The loss of consistency is seldom 
complete, though cases of this character are encoun- 
tered. Fluidity of the vitreous body does not in itself 
cause inconvenience; but it probably predisposes to 
detachment of the retina, being usually attended bv 
subnormal intraocular tension, and it may lead to com- 
plications in operations, such as extraction of cataract, 
or wounds which involve penetration of the coats of the 
eye. Treatment is ineffectual. 

Opacities of the Vitreous Humor. — The vitreous 



DISEASES OF THE VITREOUS HUMOR. 335 

humor may be diffusely clouded, or it may con- 
tain discrete opacities, varying greatly in size and num- 
ber. Inflammation of the uveal coat, at all severe, is 
commonly attended by more or less marked loss of 
transparency of the vitreous body. At first the opacity 
is apt to be diffuse; but at a later stage, instead of a 
uniform cloudiness, we have ragged masses or shreds, 
resembling bits of cobweb, which float about freely, 
indicating, at least, partial synchysis. In time, and 
when the conditions are favorable, an opacity so dense 
as not only to preclude a view of the background of the 
eye with the ophthalmoscope, but to do away with all 
fundus reflex, and to reduce vision to mere light per- 
ception, may disappear completely, leaving no trace 
which the ophthalmoscope can discover. Discrete 
opacities, which seldom are stationary, but float about 
with considerable freedom, often cause much annoy- 
ance by obstructing the view especially of small objects 
through interference with the rays of light in their pas- 
sage to the fundus of the eye, and by casting shadows 
upon the retina. 

"Vitreous opacities" of considerable size can be 
detected easily with the ophthalmoscope, and their 
movements and position in the posterior chamber of the 
eye determined. Opacities too small to be seen in this 
way are not of moment, and yet such microscopic opac- 
ities, known as muscce volitantes, which exist in all 
eyes, and under certain conditions, as when one looks 
toward a white wall or a light cloud, can always be 
perceived by the individual, give rise to much uncalled- 
for anxiety. There is a wide-spread popular belief, 
often difficult to combat, that the presence of "muscae" 
is indicative of impending blindness — of the develop- 
ment of cataract or what not. It is undoubtedly true 



336 PREVALENT DISEASES OF THE EYE. 

that they are more numerous and more conspicuous in 
eyes made irritable by refractive or muscular anomalies, 
and to this extent they are significant; but the dread 
which they so often inspire is entirely unwarranted. 

Hemorrhages into the vitreous humor which have 
undergone but partial absorption may give rise to large 
floating opacities, and opacities which are composed of 
an organized inflammatory exudate, accompanied by 
new-formed blood-vessels, and which shoot out into 
the vitreous humor from the retina, are observed in 
certain types of retinitis. 

Treatment. — The treatment of opacities of the vit- 
reous humor is the treatment of the condition or con- 
ditions upon which they depend. The major opacities, 
as has been stated, are usually caused by inflammation 
of the uveal coat, and this must be combated by the 
means described in the chapters in which diseases of 
the iris and ciliary body and of the choroid coat are dis- 
cussed. The minor opacities (muscae), when con- 
spicuous, suggest, as has just been intimated, accommo- 
dative or muscular strain, and their existence should 
lead to a careful search for optical and muscular faults, 
and to an equally careful correction of these, by glasses 
or by operation, should they prove to be present. The 
lotion of opium, by lessening the irritability of the eyes, 
will also be found useful. 

Hemorrhage into the vitreous humor occurs as 
a result of injuries of the eye, of disease of the 
choroid coat or retina, or in consequence of angioscle- 
rosis or of alterations in the composition of the blood. 
It takes place usually from the vessels of the choroid, 
less often from those of the ciliary body or retina. It 
has been observed at times in association with frequent 
attacks of epistaxis, also, in recurrent form, in connec- 



DISEASES OF THE VITREOUS HUMOR. ^J 

tion with delayed menstruation. When the extravasa- 
tion is considerable, vision may be reduced to light per- 
ception, and the ophthalmoscope may give only a black 
or reddish-black reflex. In some instances the blood 
is evenly diffused throughout the vitreous body, and 
then objects, which are seen indistinctly, have a reddish 
color, and the fundus of the eye is seen with the ophthal- 
moscope as through a red mist. Oftener it is in ill- 
defined, opaque masses, which, according to their po- 
sition, may or may not prevent a view of the optic disc 
and neighboring parts. 

The absorption of the blood from the vitreous cham- 
ber is much more tedious than from the aqueous cham- 
ber, and is not so surely complete, floating opacities, 
as has been stated, being left in the vitreous humor, 
not infrequently, as the result of its incomplete disap- 
pearance. In cases of recurrent hemorrhage sight is apt 
to suffer serious and permanent injury; but usually after 
a single hemorrhage, when finally the extravasated blood 
has disappeared, vision regains its former standard. 

Treatment. — Rest of the eyes and avoidance of active 
exercise, for a time at least, are indicated. Ergot is 
supposed to lessen the likelihood of a recurrence of the 
hemorrhage; but adrenalin, it would seem, should be 
still more efficacious. Habitual constipation, if present, 
should be corrected, aloin, in such doses as may be 
found necessary, being especially useful for this pur- 
pose. Potassium iodid should be given in five- to ten- 
grain doses, as it unquestionably promotes the absorp- 
tion of extravasated blood from the vitreous, as well as 
from the aqueous, chamber. Local remedies are of 
but little value; though, when the absorption of the 
hemorrhage is tardy, subconjunctival injections of salt 
solution are serviceable. 



CHAPTER X. 

DISEASES OF THE CHOROID COAT, RETINA, AND 
OPTIC NERVE. 

Although, without the help of the ophthalmoscope, 
it is impossible to diagnosticate with accuracy, and for 
this reason to treat intelligently, the several affections to 
be considered in this chapter, the physician who is not 
an ophthalmoscopist need not be wholly at a loss in 
dealing with these diseases of the deeper eye structures; 
for they are commonly attended by certain objective 
and subjective symptoms which are fairly pathogno- 
monic, and which when taken into account permit, at 
least, of approximate accuracy in diagnosis. 

As a rule, it may be stated, no external signs of in- 
flammation are observable in choroiditis, in retinitis, 
or in optic neuritis. Nor are these affections commonly 
accompanied by ocular pain, or by photophobia, or 
lacrimation. Obscuration, more or less marked, of 
both distant and near vision is the most constant and 
conspicuous subjective symptom, while enlargement of 
the pupil and sluggishness in its response to light are the 
chief objective symptoms. Exceptionally, as in intra- 
ocular neuritis, or choked disc, and in diseases affecting 
chiefly the periphery of the choroid or retina, very good 
central vision may exist in spite of the fact that pro- 
nounced changes observable with the ophthalmoscope 
are present; and in inflammation of the choroid, if the 
ciliary body be involved, there will almost surely be 
present pericorneal injection, pain, photophobia, sensi- 

338 



CHOROID, RETINA, OPTIC NERVE. 339 

tiveness of the eyeball to pressure, etc. But these are 
the exceptions which lend force to the rule that has been 
enunciated, and, speaking broadly, it may be said that 
disease of the optic nerve or retina, or of the choroid and 
retina (for the retina seldom escapes involvement when 
there is considerable inflammation of the choroid), is to 
be suspected when the pupil is enlarged and responds 
imperfectly to light, and when, glaucoma having been 
excluded, distant as well as near vision is impaired, and 
is growing progressively worse. 

It should be borne in mind, moreover, in endeavoring 
to reach a diagnosis, that the affections under considera- 
tion, though encountered in infancy and childhood, 
are more common in middle and advanced life; that 
they are usually binocular; that they are generally due 
to some constitutional disorder, such as syphilis, neph- 
ritis, diabetes, angiosclerosis, etc.; that they may occur 
during the course of the exanthematous fevers or as a 
complication in pregnancy; and as to optic neuritis that 
it is very commonly the result of coarse intracranial 
disease. However, it goes without saying that in these 
grave affections the physician should not rest content 
with a supposititious diagnosis, but that he should call 
to his aid a competent ophthalmoscopist, so that all 
uncertainty as to what is the true condition may be 
dispelled. 

The treatment of these deeper diseases of the eye,, 
local measures being of but little value, is mainly con- 
stitutional, and should be directed to the underlying sys- 
temic disorder upon which they depend. The prog- 
nosis, so far as sight is concerned, depends largely upon 
whether this underlying malady is or is not remediable. 
As a rule, those affections that are of syphilitic origin 
are the most amenable to treatment; while, as might be 



340 PREVALENT DISEASES OF THE EYE. 

supposed, the prognosis is least favorable in those due 
to diabetes, to nephritis, to degenerative changes in the 
vessel walls, and to non-luetic intracranial disease. 



DISEASES OF THE CHOROID COAT. 

Choroiditis, or inflammation of the choroid coat, 
occurs as a purulent, as a serous, and as a plastic process. 
Purulent choroiditis is but another name for purulent 
panophthalmitis, which has been considered in the pre- 
ceeding chapter, while serous choroiditis, which is 
synonymous with serous uveitis, has been treated of in 
connection with diseases of the iris. 

Plastic Choroiditis. — This is the more common 
variety of choroidal inflammation, and is oftenest due 
to syphilis, inherited or acquired. It is also frequently 
present in progressive myopia, and is not rarely a result 
of traumatism. 

Syphilitic inflammation of the choroid occurs usually 
in association with iritis and cyclitis, but well-marked 
cases of choroiditis are encountered in which neither 
the iris nor the ciliary body is involved; while in some 
instances, reversing the usual order, the inflammation 
begins in the choroid and extends from there to the cil- 
iary body and iris. It occurs oftenest in the secondary 
stage of the disease, but may manifest itself at a later 
period. In every pronounced case of luetic choroiditis 
the retina is invariably implicated, and, if the macular 
region is involved in one of the areas of more intense 
inflammation which are characteristic of the disease, 
decided and permanent impairment of vision usually 
results. On the other hand, if this region is not seri- 
ously involved, there may be but little permanent dam- 
age to sight, though for a time it may be reduced to mere 



DISEASES OF THE CHOROID COAT. 34I 

light perception, owing largely to opacity of the vitreous 
humor. 

Loss of transparency of the vitreous humor is a usual 
feature of syphilitic choroiditis. At first the opacity is 
diffuse, and often so dense as to render a view of the 
background of the eye with the ophthalmoscope im- 
possible. At a later stage, instead of this uniform 
clouding, we have ragged, cobweb-like opacities, which 
float more or less freely in the relatively clear vitreous 



'-■--X 








/ 



Fig. 131. — Fundus changes consequent upon severe (probably syphilitic) 
choroiditis, as seen with the ophthalmoscope (de Wecker). 

body, and impair sight to a greater or less extent ac- 
cording to their position with reference to the visual 
axis. Ultimately these floating opacities usually dis- 
appear, and with their disappearance excellent vision 
may be regained, provided the retina, its central portion 
more especially, has not suffered serious damage (Fig. 

130- 

The disease runs a tedious course, a course of months 
rather than weeks, and is apt to attack both eyes, 
though energetic treatment not infrequently prevents 



342 PREVALENT DISEASES OF THE EYE. 

involvement of the second eye. Its existence should be 
suspected whenever, especially during the secondary 
stage of syphilis, marked impairment of vision, unat- 
tended by pain or injection of the eye, occurs. The 
presence of pain and circumcorneal injection indicates, 
as has been pointed out, that the iris and ciliary body 
are involved in the inflammatory process. 

In the subjects of inherited syphilis plastic choroiditis 
occurs most frequently in association with interstitial 
keratitis, and under such circumstances iritis also is 
often present. It may make its appearance at any 
period of life, even as a prenatal affection; but, like inter- 
stitial keratitis, it is encountered oftenest between the 
ages of six and fifteen or sixteen years. The prognosis 
is unfavorable; but much may be accomplished by 
promptly instituted treatment. Opacity of the lens is 
a not uncommon consequence of unchecked syphilitic 
choroiditis. 

The choroiditis of myopia of high grade is less in- 
tense than the syphilitic type; but as it occurs at the 
posterior pole of the eye and frequently involves the 
macular region, and as the retina is always implicated, 
the consequences to vision are often disastrous (Fig. 
132). Floating vitreous opacities, large enough to cause 
considerable annoyance, are usually present, and de- 
tachment of the retina, and the development of cataract 
from disturbance of the nutrition of the lens, are com- 
plications to be apprehended. 

Plastic choroiditis of traumatic origin, with which 
iritis and cyclitis are often associated, arises most fre- 
quently from penetrating wounds of the eye complicated 
by hernia of some portion of the uveal coat. The lodg- 
ment of a foreign body in the eye is especially apt to give 
rise to it. When such injuries are attended by the 



DISEASES OF THE CHOROID COAT. 



343 



entrance of a pyogenic micro-organism into the interior 
of the eye a purulent panophthalmitis is apt to super- 
vene; but when this is not the case a less intense inflam- 
mation, of plastic character, usually results. The 
prognosis in these cases is distinctly unfavorable, and 
enucleation of the eye is often demanded to prevent 
sympathetic implication of the fellow-eye. 

Miliary Choroido-retinitis. — As a result of accom- 




Fig. 132. — Eye-ground in progressive myopia. Large posterior staphy- 
loma surrounding the nerve -head. Macular region occupied by an area of 
semi-atrophic choroido-retinitis (de Schweinitz). 



modative strain, especially in astigmatic eyes which 
without glasses or with improperly adjusted glasses 
are much taxed in reading, writing, etc;, a low grade 
of choroiditis, or rather choroido-retinitis, is of very 
common occurrence; and because of the frequency of 
its occurrence, and the serious consequences, near and 
remote, to which it gives rise, this affection deserves fuller 
consideration than is commonly accorded it in text- 



344 PREVALENT DISEASES OF THE EYE. 

books upon eye diseases. In treating of the etiology 
of glaucoma and of cataract the significance of this 
condition has already been emphasized. 

Unlike the severer types of choroiditis which have 
been described, this affection, in its early stages at all 
events, is not attended by marked impairment of sight. 
Instead, we have irritability of the eyes, photophobia, 
easily provoked lacrimation and conjunctival hyper- 
emia, and, not infrequently, blepharitis marginalis and 
frontal headache — in a word, we have, in intensified 
form, the complex of symptoms which constitutes asthen- 
opia. At first the ophthalmoscope shows a markedly 
hyperemic disc and, especially in the neighborhood of 
the disc and the macula, an undue retinal reflex, indic- 
ative of edema of the retina. After a time this retinal 
edema disappears, and, instead, we find, and again 
most marked in the region of the macula and between 
it and the disc, miliary changes in the choroido-retinal 
pigment — an appearance as though fine black pepper 
had been dusted over the background of the eye. (See 
Frontispiece.) In after years, when possibly incipient 
cataracts or the premonitory symptoms of glaucoma are 
manifesting themselves, there is observed a general 
thinning of the pigment of the choroid and retina, show- 
ing too plainly the choroidal vessels, with the islands of 
pigment between them — the so-called "patchy" cho- 
roid with which every ophthalmoscopist is familiar. 

The frequency with which this state of the choroid, 
indicative, as I believe it is, of a precedent "miliary" 
choroido-retinitis, is found in cataractous and in glau- 
comatous eyes must have attracted the attention of 
every one who has carefully studied such eyes. To my 
mind it is clear that the connection between these con- 
ditions is not merely accidental. On the contrary, I 



DISEASES OF THE CHOROID COAT. 345 

am persuaded that a definite causative relation exists 
between the strain of accommodation, the miliary 
choroido-retinitis to which it gives rise, and the later 
occurrence of cataract or glaucoma, as the case may 
be. Other factors doubtless play a part, especially 
with reference to the supervention of glaucoma, but the 
long-continued accommodative strain, not infrequently, 
is the dominant one. 

How many of these serious maladies of advanced life 
might be prevented by the early recognition and careful 
correction of the errors of refraction with which they are 
so often found associated it is difficult to say. But I ven- 
ture to predict that when the medical profession and the 
laity have learned how important a role these errors 
plav in the causation of ocular diseases, and, further- 
more, that their determination and correction, — so far 
from being a trivial matter to be left to the tyro who, 
calling himself an "examining optician," undertakes to 
"fit glasses," — demand the best efforts of the physician 
trained in this department of medicine, there will be a 
very material reduction in the number of eves requiring 
operation for glaucoma or for cataract, and probably, 
too, of eves in which sight is irretrievably impaired 
through pathological changes in the retina or its blood- 
vessels. 

Treatment.- — In choroiditis of syphilitic origin local 
remedies are of but little value; but one should be on 
the lookout constantly for the supervention of iritis, and 
immediately upon the appearance of symptoms indica- 
tive of its occurrence, such as pericorneal injection, pain, 
photophobia, and lacrimation, should employ atropin 
freely. The constitutional remedies chiefly to be relied 
upon are mercury and potassium iodid, and these to be 
effectual must be given persistently and in liberal doses. 



34^ PREVALENT DISEASES OF THE EYE. 

The biniodid of mercury in doses of a sixteenth of a 
grain, or the protoiodid in one-fourth of a grain doses, 
should be given three times a day, and with either of 
these potassium iodid may often be combined advan- 
tageously. In addition, inunctions of mercurial oint- 
ment should be employed in severe or intractable cases. 
Heroic doses of potassium iodid not infrequently prove 
valuable. As a rule, in the cases due to inherited lues 
less energetic treatment is demanded, though here, too, 
it must be persisted in. One should not be disap- 
pointed if the response to the remedies employed is 
tardy, for this is what must be expected. 

In the choroiditis of high myopia it is of the first im- 
portance that the eyes should be taxed but little in near 
vision, and that carefully adjusted glasses should be 
prescribed — glasses which, as a rule, leave a part of the 
myopia uncorrected, but which take into account any 
astigmatism or muscular fault that may be present. 
The long-continued use of the lotion of opium and bor- 
acic acid is also of undoubted value. It should be 
applied at bedtime on gauze or linen pads, and the pads, 
kept in place by a light bandage, should be allowed to 
remain in position until morning. It may seem that 
such a remedy, applied in this way, could hardly be 
efficacious; but it unquestionably lessens the irritability 
of the eyes, and probably reduces the hyperemia of the 
deeper ocular tunics. We know that belladonna used 
in a similar manner finds its way into the circulation of 
the eye, and produces its characteristic effect, and there 
is no reason why opium should not do the same. 

In non-suppurative traumatic choroiditis sodium 
salicylate, in generous doses, is the most useful rem- 
edy that we possess. Mercury also is at times service- 
able. Atropin and the lotion of opium and boracic 



DISEASES OF THE CHOROID COAT. 



347 



acid are indicated when, as is often the case, pain 
and photophobia are present. 




Fig. 133. — Sarcoma of the choroid with complete detachment of the retina 
(Leber). The tumor, G, rises from the choroid, C, which ever}- where lies 
in contact with the sclera. The retina, 2V, on the contrary, is detached 
entirely from its bed under the form of a folded funnel. It retains its con- 
nection only with the papilla behind, and with the choroid along the ora 
serrata, O, in front. 









'iJ^H 


' 











Fig. 134. — Sarcoma of the choroid, advanced stage (Haab). 



As might be supposed, in dealing with miliary chor- 
oido-retinitis the most important indication is the care- 
ful correction of the refractive error or muscular fault 



348 PREVALENT DISEASES OF THE EYE. 

which has brought it about. Exceptionally, prolonged 
rest of the eyes is called for; but usually the trouble 
itself and the symptoms which characterize it disappear 
promptly when proper glasses are prescribed. The 
lotion of opium, just spoken of, is very useful in this 
condition also, and the patient's general condition, 
especially the digestive apparatus and the state of the 
bowels, should be looked after. 

Tumors of the choroid are of infrequent occurrence, 
and are commonly of malignant type, sarcoma of the 
choroid being oftenest encountered (Figs. 133 and 134). 
As soon as their malignant nature is recognized, imme- 
diate enucleation of the eye is demanded; but even when 
this measure is resorted to at an early stage of their de- 
velopment there is no assurance that the disease will not 
manifest itself elsewhere. 

Congenital anomalies of the choroid are compara- 
tively rare, and need not engage our attention. 

DISEASES OF THE RETINA. 

RETINITIS. 

Retinitis, or inflammation of the retina, occurs as a 
primary and as a secondary afFection. When mild in 
type, and attended only by hyperemia and edema, it is 
known as serous retinitis; when more severe, and ac- 
companied by hemorrhage and round-cell infiltration, 
it is denominated parenchymatous retinitis. Inflam- 
mation of the retina is not attended, as might be sup- 
posed, by photophobia, nor is it accompanied by pain. 
Impairment of vision is the chief subjective symptom; 
enlargement and sluggishness of the pupil are almost 
the only objective symptoms, apart from the evidence 
afforded by the ophthalmoscope. When the inflamma- 
tion involves the region of the macula the disturbance 



DISEASES OF THE RETINA. 349 

of sight is pronounced; when it is limited to the outlying 
portions of the retina there is commonly only circum- 
scription of the visual field, which may cause but little 
annoyance. Parenchymatous retinitis is usually bilat- 
eral, and commonly runs a tedious course, and, if un- 
checked, leads to atrophy of the nervous elements of the 
retina, with attendant hypertrophy of the supporting 
tissue, and obliteration of the blood-vessels. 

The usual causes of primary retinitis are syphilis, 
nephritis, diabetes, splenic leucocythemia, pernicious 
anemia, gout, and angiosclerosis. It may also result 
from embolism or thrombosis of the central artery of the 
retina, or one of its chief branches, and from thrombosis 
of the central vein, while exceptionally it is produced 
by some direct exciting cause, such as undue exposure 
of the eye to the direct rays of the sun or to the electric 
arc light. Prolonged accommodative strain is another 
cause, though this commonly gives rise to a choroido- 
retinitis, of which we have already spoken. 

Secondary retinitis is usually consequent upon inflam- 
mation of the uveal coat or of the optic nerve. It may 
occur also as a result of serious injury of other eye 
structures. 

Retinitis Albuminurica (Nephritic Retinitis). — 
Retinitis occurs in all forms of kidney disease at- 
tended by albuminuria, but especially in chronic inter- 
stitial nephritis. It is met with also in the albumi- 
nuria of pregnancy and in that of scarlatina. It is not 
infrequently a comparatively early symptom of nephri- 
tis, and is almost always bilateral. It is said that a 
majority of the patients suffering with kidney disease 
die within two years of the appearance of the retinal 
lesion, and that to live for five years is rare. As it 
commonly involves the region of the macula, it is usually 



35° PREVALENT DISEASES OF THE EYE. 

attended by marked impairment of vision. The occur- 
rence of a hemorrhage in this region may cause a sud- 
den and pronounced impairment of sight. The severity 
of the eye lesion, it should be remarked, does not bear a 
constant relation to the severity of the kidney affection. 
The retinal changes consist of degeneration of the 
walls of the blood-vessels, round-cell infiltration, numer- 
ous hemorrhages, and rapidly occurring fatty degener- 




Fig. 135. — Albuminuric retinitis (Haab). 

ation of the infiltrate and of the retina itself. The 
ophthalmoscopic picture presented by these changes 
is very characteristic (Fig. 135), and for this reason 
it often happens that an examination of the eyes 
reveals the true nature of the patient's malady before 
other suggestive symptoms have manifested themselves. 
The discovery of retinitis should always lead to a 
careful analysis of the urine. 



DISEASES OF THE RETINA. 35 1 

A sudden and pronounced impairment of vision, due 
to uremia, may occur in any of the varieties of albumin- 
uria, but especially in the albuminuria of pregnancy and 
in that due to the eruptive fevers (uremic amblyopia). 
With improvement in the patient's general condition 
vision commonly returns to its former standard. 

In the albuminuria of pregnancy and of scarlatina 
the prognosis as to vision is favorable; but, as might 
be supposed, the outlook is grave when this condition 
is due to organic disease of the kidneys. Even under 
such circumstances, however, I have occasionally seen 
the retinal lesion improve decidedly, and seemingly as 
a result of the treatment instituted. Fortunately, sight 
is seldom completely lost, for death usually occurs be- 
fore this happens. 

Treatment. — So far as the eyes themselves are con- 
cerned the treatment consists solely in care in their use, — 
not necessarily absolute avoidance of reading, writing, 
etc., but very moderate indulgence in such occupa- 
tions — and in the careful adjustment of glasses to 
correct any refractive or muscular fault that may be 
present. This latter measure is of much importance, 
and, by relieving the eyes of all strain, may do more than 
anything else to preserve the sight. Apart from these 
local measures, treatment is to be directed to the neph- 
ritis and to the patient's general condition. Tincture of 
iron, in liberal doses, is at times distinctly beneficial. 
Basham's mixture is also useful, and so, in some in- 
stances, is potassium iodid, administered in small doses. 

Diabetic Retinitis. — This occurs as a late mani- 
festation of the disease, and is always bilateral. It 
is not infrequently complicated by cataract and oc- 
casionally by plastic iritis or glaucoma. The fundus 
changes are not wholly unlike those observed in neph- 



352 PREVALENT DISEASES OF THE EYE. 

ritic retinitis, but are less sure to involve the region of 
the macula. Hemorrhages into the retina are common, 
and extravasations of blood into the vitreous humor 
occur. As in other forms of retinitis, the extent to 
which sight is impaired depends in large measure upon 
the involvement or non-involvement of the macula in the 
inflammatory process. The prognosis, of course, is 
unfavorable, and depends upon whether or not the 
patient's general condition can be improved. An oph- 
thalmoscopic examination is demanded whenever fail- 
ure of sight occurs during the progress of a case of 
diabetes. It may reveal either retinitis or incipient 
cataract. 

Treatment. — Besides moderation in the use of the 
eyes and the prescribing of suitable glasses, treatment 
consists chiefly in regulating the diet and habits of 
life of the patient. 

Leucocythemic Retinitis. — This seldom occurs 
except in the splenic variety of the disease. The retinal 
changes consist of emigration of leucocytes and numer- 
ous hemorrhages. As seen with the ophthalmoscope, 
the light color of the background of the eye, with the 
distended and rose-red veins, the contracted and orange- 
yellow arteries, and the pale optic disc form a striking 
picture. Both eyes are involved, and the ocular lesion 
commonly increases with the progress of the general dis- 
ease. The treatment is that of the systemic condition. 

Retinitis of Pernicious Anemia. — This affection 
closely resembles leucocythemic retinitis, and the 
ophthalmoscopic changes are of much the same, 
character. One or both eyes may be involved, and 
after temporary improvement relapses frequently occur. 
The prognosis as to vision is distinctly unfavorable. 

Treatment, as recommended by Osier, consists of rest 



DISEASES OF THE RETINA. 353 

in bed, with a light nutritious diet, massage, and in- 
creasing doses of arsenic. 

Syphilitic Retinitis. — Syphilitic inflammation of 
the retina, without accompanying involvement of the 
choroid, is rare, but is described by most authors, 
and is said to occur in the inherited as well as in the 
acquired form of the disease. Exudations, especially 
along the retinal vessels, and vitreous opacities make 
their appearance, while hemorrhages are rare, and there 
is an absence of the pigment changes seen in syphilitic 
choroido-retinitis. One or both eyes may be involved, 
and the affection may develop within a few months 
of the initial lesion or at a much later period. The 
process is usually a chronic one, and not infrequently 
results in marked impairment of sight. If treatment 
is promptly instituted, however, the prognosis is not un- 
favorable. 

Treatment. — Energetic antisyphilitic treatment is 
indicated. The biniodid of mercury, with or without 
potassium iodid, is especially useful, and in individuals 
showing an insusceptibility to mercury, its administra- 
tion may be supplemented by inunctions of blue oint- 
ment. 

Retinitis from Exposure of the Eyes to In- 
tense Light. — Retinitis resulting from undue expo- 
sure of the eyes to the direct rays of the sun — 
oftenest brought about by observing an eclipse of the 
sun without proper protection of the eyes — and to in- 
tense electric light, as in electric welding, usually mani- 
fests itself in the region of the macula, where at first 
edema, and later miliary pigment changes, are observable 
with the ophthalmoscope. The visual disturbance is 
characterized at the outset by a persistent after-image, 
and this is followed by a decided, usually small, central 
23 



354 PREVALENT DISEASES OF THE EYE. 

scotoma, which may be attended by subjective sensa- 
tions of light. From the action of the electric light, 
in addition to the retinitis, considerable ciliary irritation 
and conjunctivitis sometimes result, an effect, it would 
seem, of the ultra-violet rays, comparable to that which 
is produced by the too-prolonged action of the "X" 
rays or by the emanations of radium. 

The symptoms commonly disappear slowly, and the 
eyes ultimately resume their normal state; but excep- 
tionally the outcome is not so favorable, and a more or 
less pronounced impairment of central vision remains. 

Treatment consists in complete rest of the eyes, and 
in their protection from bright light by smoke-tinted 
glasses. The lotion of opium and boracic acid is indi- 
cated, and the occasional administration of a purgative 
may do good. 

Retinitis Pigmentosa (Pigmentary Degenera- 
tion of the Retina). — This singular and interest- 
ing affection, which invariably involves both eyes, 
makes its appearance in childhood, when it is not 
congenital, and progresses slowly with advancing 
age. Little is known as to its etiology except that, not 
infrequently, inheritance seems to be an important fac- 
tor, and that it is met with sufficiently often in the off- 
spring of consanguineous marriages to make the fact 
noteworthy. Probably the latter circumstance ex- 
plains its frequent association with congenital anom- 
alies, such as harelip, mental deficiency, deaf-mutism, 
etc. From five to ten per cent, of congenital deaf- 
mutes, it is said, are afflicted with this disease. In- 
stances in which cases have occurred in several genera- 
tions of the same family are not uncommon. For some 
reason, as yet not understood, females are less suscep- 
tible to the disease than males. 



DISEASES OF THE RETINA. 355 

Inherited syphilis is usually given as one of the 
causes of retinitis pigmentosa. My own experience is 
not in accord with this view, and I am disposed to be- 
lieve it is the result of confounding syphilitic dissemi- 
nated choroido-retinitis with true retinitis pigmentosa, 
which it sometimes closely resembles. 

One of the earliest symptoms of the disease, and 
the most characteristic, is night-blindness; progressive, 
concentric contraction of the visual field is another 
prominent symptom. Ultimately there is marked 
failure of central vision, though complete blindness is 
rare, or, at all events, does not come on until quite late 
in life. Nystagmus is not infrequently present, espe- 
cially in cases of congenital origin. 

The failure of vision is due to a slowly progressive 
atrophy of the retina and optic nerve, attended by 
marked narrowing of the retinal vessels, and by the 
peculiar deposition of pigment from which the 
disease derives its name. The deposits of pigment, 
which often lie along the course of the vessels, are 
stellate in form, and resemble bone corpuscles as seen 
with a microscope of low power. At first these deposits 
are confined to the periphery of the fundus, and are 
detected, perhaps, w T ith some difficulty with the ophthal- 
moscope; they slowly advance, however, toward the 
optic nerve and macula, and ultimately are scattered 
over the whole background of the eye. The ophthal- 
moscopic picture presented is a very characteristic one, 
and should not be mistaken for any other condition 

(Fig. 136). 

The decline of vision, as has been said, is very gradual, 
but the prognosis as to the final outcome is most un- 
favorable, for treatment is of little or no avail. In 
every case of defective night vision, especially if of con- 



35^ PREVALENT DISEASES OF THE EYE. 

siderable duration and progressive in character, the 
existence of retinitis pigmentosa should be suspected, 
and a careful ophthalmoscopic examination, directed 
particularly to the periphery of the eye-grounds, should 
be made. One of the later complications of the disease, 
not infrequently observed, is the development of pos- 
terior polar cataract, which, of course, further markedly 
impairs vision. 




Fig. 136. — Advanced stage of retinitis pigmentosa. The optic nerve 
shows pronounced atrophy, and the retinal vessels have nearly disappeared 
(Jaeger). 



Treatment. — As pronounced refractive errors are 
often associated with retinitis pigmentosa, they should 
be carefully searched for, and as carefully corrected 
by glasses if found to be present. Moderation in the 
use of the eyes should be enjoined and the avoidance 
of occupations which involve much reading, writing, 
sewing, and the like. Strychnin given from time to 
time, in moderate doses and for considerable periods, 



DISEASES OF THE RETINA. 357 

seems in some cases to be of benefit; galvanism also is 
recommended, and potassium iodid may be tried when 
other measures have failed. 
Embolism of the Central Artery of the Retina. 

— The lodgment of an embolus in the central artery of 
the retina, which is usually a consequence of valvular 
disease of the heart or of aneurism, causes sudden and 
complete loss of sight of the affected eye. In rare 
instances the embolus becomes dislodged or breaks 
down, and vision is restored; but such improvement 
in sight as occurs occasionally from the establishment 
of a collateral blood-supply almost always proves 
to be but temporary. When the obstruction takes 
place in a branch of the artery central vision may re- 
main unimpaired, and there may result only a more or 
less marked contraction of the visual field. 

Pronounced edema of the retina develops within a 
few hours of the lodgment of the embolus, and this is 
accompanied by marked diminution in the size of the 
retinal arteries. Hemorrhages, especially in the macu- 
lar region, may occur. Ultimately atrophy of the 
retina and optic nerve ensues. 

The picture revealed by the ophthalmoscope is very 
characteristic and striking (Fig. 137). The edematous 
condition of the retina gives to the general eye-ground a 
whitish appearance; but as the edema does not involve 
the macula the red color of the choroid shows plainly at 
this point. The contrast in color is pronounced, and 
the condition is spoken of as "the cherry-red spot at the 
macula. " 

It is probable that a not inconsiderable number of 
the cases which in the past have been diagnosticated 
as " embolism" of the central retinal artery, but in 
which none of the cardiac or vascular conditions apt 



35$ PREVALENT DISEASES OF THE EYE. 

to give rise to the formation of an embolus was present, 
were really cases of rapidly forming thrombotic obstruc- 
tion of the artery. 

Treatment.- — This has for its object the possible dis- 
lodgment of the embolus, so that it may find its way into 
one of the subdivisions of the artery, where the ill con- 




Fig. 137. — Embolism — or thrombosis — of the central artery of the retina 

(Haab). 



sequences of its presence will be of less moment. With 
this end in view the eye should be rather energetically 
massaged, and nitrite of amyl should be administered 
by inhalation for the purpose of causing transient dila- 
tation of the artery. These measures have in some 
instances proved effectual. 



DISEASES OF THE RETINA. 359 

Thrombosis of the central artery of the retina 

commonly results from degenerative changes in the 
arterial coats or from alterations in the compo- 
sition of the blood. The symptoms which attend it 
are similar to those observed in embolism, except that 
the final loss of sight is often preceded by transient 
obscurations of vision and by attacks of giddiness, 
faintness, and headache. The ophthalmoscopic pic- 
ture is essentially the same. (See Fig. 137.) 

It seems probable that the cases of sudden loss of 
sight following severe hemorrhage, especially hem- 
orrhage from the stomach, are due in most instances 
to thrombotic obstruction of the retinal artery, excep- 
tionally, perhaps, to similar obstruction of the retinal 
vein.* 

The treatment is the same as that employed in em- 
bolism. 

Thrombosis of the central retinal vein occurs 
usually in elderly persons who are afflicted with or- 
ganic disease of the heart or angiosclerosis; it may 
result also from alterations in the state of the blood, 
such as occur from excessive hemorrhage, or in conse- 
quence of orbital disease or disease of the cavernous 
sinus. Facial erysipelas, through extension to the orbit, 
may give rise to it. One or both eyes may be involved. 

Loss of sight is not so sudden as in embolism of the 
artery, and the prognosis is somewhat less hopeless, 
though blindness from atrophy of the retina and optic 
nerve is the usual outcome. In some instances a glau- 

* In the report of "A case of atrophy of the optic nerve following 
hemorrhage from the stomach, with a consideration of the causes of 
post-hemorrhagic blindness," published in the "Am. Journal of Oph- 
thalmology" for May, 1899, and in the "Johns Hopkins Hospital Bul- 
letin" of the same date, this view was advocated by the author, and 
evidence set forth in support of it. 



360 PREVALENT DISEASES OF THE EYE. 

comatous condition supervenes, and gives rise to much 
suffering. 

The ophthalmoscope shows edema of the retina with, 
perhaps, more definite areas of exudation, enormous 
distention and great tortuosity of the retinal veins, and 
numerous flame-shaped hemorrhages scattered over 
the entire fundus (Fig. 138). "Hemorrhagic retinitis'* 




Fig. 138. — Thrombosis of the central retinal vein (Haab). 

was the name formerly given to this condition, before 
its essential nature was understood. 

Treatment is of but little avail. An energetic cathar- 
tic, followed by potassium iodid, may possibly accom- 
plish some good. 

Detachment of the Retina.— In view of the fact 
that the retina is attached only about the optic nerve 
margin and at the ora serrata, and that elsewhere it is 
kept in apposition with the choroid simply through the 



DISEASES OF THE RETINA. 361 

support afforded by the vitreous humor, it is little matter 
for surprise that it should at times become "detached," 
or separated from the other coats of the eye. Indeed, 
the wonder is that this misadventure does not happen 
more frequently than it does; and I can not but feel 
that some of the elaborate and far-fetched theories 
which have been advanced to explain its occurrence are 
as uncalled for as they are unsatisfying. For example, 
one of these theories, which has been accepted by 
many, holds that bands which have formed in the vitre- 
ous humor, by contraction, drag upon the retina with 
such force as finally to tear a rent in it, and that through 
this rent fluid from the vitreous chamber passes, and 
causes the detachment. Why the retina does not yield 
directly to the traction, and what causes it, since it is 
not adherent to the choroid, to resist the drag upon it 
to the point of being torn, the proposers of the theory do 
not explain; nor do they tell us why the sub retinal fluid 
might not be supplied by the vascular uveal coat quite 
as well as by the non-vascular vitreous body. 

As a matter of fact, detachment of the retina, when 
it is not due to a serious traumatism, usually occurs in 
eyes which have been the seat of long-standing disease, 
especially disease of the uveal coat, myopia of high grade 
being the condition in which it oftenest takes place. 
It is also a common result of the development of intra- 
ocular tumors. That in these several conditions a pre- 
disposition exists to the occurrence of hemorrhagic or 
serous effusion from the very vascular choroid coat 
goes without saying, and it is doubtless in this way that 
detachment of the retina usually is brought about, the 
immediate cause of such an effusion being, very often, 
a violent spell of coughing or vomiting, a fall, a blow 
upon the head, or an unusual strain, as in lifting a heavy 



362 PREVALENT DISEASES OF THE EYE. 

weight. In intraocular growths there is also, not infre- 
quently, a mechanical elevation of the retina by the 
growth itself, and in high myopia the staphylomatous 
yielding of the sclera at the posterior pole of the eye is 
an additional factor tending to promote separation of 
the retina from the outer tunics. 

The detachment may begin at any point, and may 
be partial or complete. When it commences in the 
upper part of the retina it usually extends downward, 
owing to the gravity of the subretinal fluid, and as this 
takes place the upper and first detached portion may 
resume its normal position with reference to the choroid, 
a striking illustration, it would seem, of the important 
role which the effusion plays in the process. Strictly 
speaking, the retina never becomes completely detached; 
for, though everywhere else separated, it always re- 
mains attached at the optic nerve entrance and at the 
ora serrata, presenting under these circumstances an 
appearance suggestive of a nearly closed umbrella (see 

Besides causing marked impairment of vision, the 
degree of impairment depending largely upon its loca- 
tion and extent, detachment of the retina is usually 
attended by subjective light sensations and by a "flick- 
ering" and confusion of sight that make an eye in which 
this condition is present a source of much greater annoy- 
ance to its unfortunate possessor than if it were quite 
blind. There are two ways in which detachment of the 
retina may impair vision. In the first place, the sepa- 
rated portion of the retina is itself incapable of useful 
vision; in the next place, it may hang or float in front 
of a part of the retina which is, perhaps, in a nearly or 
quite normal condition, the macular region, for example, 
and cut off the light from it. If the macular region is 



DISEASES OF THE RETINA. 363 

involved in the detachment or is covered by it in the 
manner just described, the sight of the eye will be of 
but little value. On the other hand, if the detachment 
is confined to the periphery of the retina, good central 
vision may be present, and there may be only a limita- 
tion of the visual field. A late complication, more apt 
to occur in myopic eyes, is the development of cataract. 

When the symptoms described make their appear- 
ance, as they usually do, suddenly, and especially in an 
eye known to be decidedly myopic, retinal detachment 
should be suspected, and an ophthalmoscopic examina- 
tion should be made. This view would be strengthened 
if the tension of the eye was found to be below normal; 
for this is usually the case in uncomplicated detachment 
of the retina. On the other hand, if increased tension 
of the globe is found in association with retinal detach- 
ment the presence of an intraocular growth is to be 
feared. 

The prognosis in detachment of the retina is most 
unpromising. In rare instances a spontaneous re- 
covery takes place, and, almost as rarely, a recovery oc- 
curs seemingly as a result of treatment. Usually the 
detachment increases, and vision goes from bad to 
worse. Unless some inflammatory complication en- 
sues pain is not experienced. The affection is com- 
moner in males than in females, probably because they 
are more liable to such accidents as may bring it about, 
and occurs much oftener in advanced life than in youth. 

Treatment. — This consists, at the outset, in rigid con- 
finement to bed and in the administration of increasing 
doses of pilocarpin, so that marked salivation and sweat- 
ing may be induced. Later potassium iodid may be 
substituted for the pilocarpin. Avoidance of consti- 
pation is indicated. Subconjunctival injections of 



364 PREVALENT DISEASES OF THE EYE. 

sterile salt solution are worthy of trial, though the results 
obtained, as in all other methods of treatment, are usu- 
ally disappointing. The injections should be repeated 
once in two or three days, the strength of the solution 
being increased gradually from two per cent, to five per 
cent, and the quantity injected from 15 to 25 minims. 
If improvement is manifested, the treatment should be 
persisted in for several weeks. 

Numerous operative procedures have been suggested 
for the cure of this condition, when less radical measures 
have proved unavailing. The most rational of these, 
and the one as apt to prove efficacious as any, consists 
in the drawing ofT of the subretinal fluid by means of an 
incision, made subconjunctivally, through the sclera 
at a point corresponding with the detachment. With 
careful antiseptic precautions this procedure is attended 
with little risk. Rest in a recumbent posture for some 
days after the operation should be enjoined. It is 
claimed, by Stillson, that more permanent results are 
obtained from perforating the sclera at one or two 
points beneath the detachment by means of the galvano- 
cautery. I have had no experience with this method, 
but it impresses me as being a rather severe procedure. 

Glioma of the Retina. — Although this very ma- 
lignant intraocular tumor is certainly, and it may be 
added fortunately, not one of the commoner diseases 
of the eye, it has seemed to me best to treat of it, for the 
reason that the early recognition of its existence is of the 
first importance, and before such cases are brought 
to the attention of the specialist they are very apt to fall 
under the observation of the general practitioner. It is 
true that, in its early stages, a positive diagnosis can not 
be made without the aid of the ophthalmoscope; never- 
theless a very shrewd guess as to what the trouble is 



DISEASES OF THE RETINA. 365 

may be hazarded as a result simply of a careful daylight 
inspection of the eye, aided by the employment of a 
mydriatic. 

Glioma of the retina is essentially a disease of child- 
hood, and generally makes its appearance during the 
first three years of life; indeed, it is not infrequently 
of congenital origin. In about one case in four both 
eyes are involved, and it occurs with equal frequency 
in males and in females. It has its starting-point com- 
monly in the inner granular layer of the retina, and is 
of rapid growth. It shows a strong disposition to in- 
vade the optic nerve, and in time causes a rupture of 




Fig. 139. — Glioma of the retina, early stage (Haab). 

the eyeball, usually either in the neighborhood of the 
optic nerve or through the cornea. 

In its early stages it is attended neither by pain nor 
by external signs of inflammation. The first evidences 
of its existence are a somewhat enlarged and sluggish 
pupil and a peculiar yellowish or grayish reflex from 
the pupil, with decided impairment of the sight of the af- 
fected eye, though the determination of this point is 
often difficult, because of the early age at which it com- 
monly develops. This striking appearance of the pupil 
led the earlier authors to designate the condition "am- 
aurotic cat's eye" (Fig. 139). 

As the tumor increases in size there is usually an 
elevation of the intraocular tension, and when this is at 



3 66 



PREVALENT DISEASES OF THE EYE. 



all pronounced pain manifests itself. At this period 
several enlarged and tortuous subconjunctival vessels 
often make their appearance. Before long the shape 
of the eye undergoes alteration, the iris becomes muddy, 
the cornea cloudy, and there is great intensification of 
the pain; and presently rupture of the eyeball occurs. 
If this takes place posteriorly pronounced proptosis 
quickly develops ; if anteriorly , a fungoid mass sprouts out 
rapidly from the place of rupture (Fig. 140), and increases 
in size so fast that in a comparatively short time it may 
be as large, or nearly as large, as the child's head, and we 




Fig. 140. — Glioma of the retina, more advanced stage (Haab). 



have the condition which formerly was known as "fun- 
gus hematodes oculi." In the meantime, by extension 
along the optic nerve, the disease, perhaps, has reached 
the brain; or, less frequently, by metastasis, has invaded 
the liver or other distant organs, and death, not any too 
soon, comes to put an end to the sufferings of the 
wretched little patient. There are few tumors which 
are as malignant as glioma of the retina, and there are 
not many diseases in which the prognosis is so wholly 
unpromising. 

treatment consists in enucleation of the eye at the 
earliest moment possible after the establishment of the 



DISEASES OF THE OPTIC NERVE. 367 

diagnosis, care being taken to divide the optic nerve as 
far behind the eyeball as practicable. If this is done 
before the growth has invaded the orbit or has extended 
to the optic nerve, there will, in all probability, be no 
local return of the disease, and, in very exceptional in- 
stances, no development of it elsewhere. Usually, how- 
ever, the child dies within two or three years, with symp- 
toms which indicate that the growth has recurred in the 
brain. 

If the tumor has invaded the orbit not only the eye, 
but the whole contents of the orbit should be removed, 
although even when this is done in the most radical 
manner a local recurrence of the growth is extremely 
probable. 

DISEASES OF THE OPTIC NERVE. 

OPTIC NEURITIS. 

Two principal varieties of inflammation of the optic 
nerve are recognized — a usually more intense form, 
which tends to involve the nerve throughout its whole 
course, is commonly consequent upon intracranial dis- 
ease, is nearly always bilateral, and is attended by 
marked inflammatory changes in the papilla; and a less 
intense form, which is limited to the orbital portion 
of the nerve, has no relation to intracranial disease, 
is usually monolateral, and is accompanied by relatively 
slight intraocular changes. The last-named variety, 
known as retrobulbar, or orbit ah neuritis, is a type of 
peripheral neuritis, and occurs as an acute and as a 
chronic affection. The first-mentioned variety, now 
commonly known as intraocular neuritis, papillitis, or 
choked disc, was formerly subdivided into descending 
neuritis and intraocular neuritis or choked disc, and, 
though definite pathologico-anatomical evidence to 



3 68 



PREVALENT DISEASES OF THE EYE. 



support this classification is lacking, from a clinical 
standpoint there seem to be good reasons for adhering 
to it. 

According to this view, a "descending" optic neuritis 
is an inflammation of the optic nerve in which the in- 
flammatory process, as the name indicates, progresses 
along the optic nerve from the brain to the eye; while 
a "choked disc," or "intraocular neuritis/' is one in 




i 9 e 

Fig. 141. — Longitudinal section of the optic nerve-head (Piersol): a, a, 
bundles of optic nerve fibers, which spread out over retina at a', a'; b, layers 
of retina; c, choroid; d, sclera, continued across optic nerve as the lamina 
cribrosa; e, g, i, respectively the pial, arachnoid, and dural sheaths of optic 
nerve, enclosing subdural and subarachnoidal lymph-spaces; /, /', retinal 
blood-vessels cut longitudinally. 



which the inflammation, believed to be caused by ob- 
struction of the blood- or lymph-currents of the optic 
nerve, or by the presence of toxins or other pathological 
products in the lymph-channels of the nerve (Fig. 141), 
begins at or in the neighborhood of the papilla, and tends 
to extend thence toward the brain. Both of these types 
of optic neuritis are characterized by vascular congestion 
and swelling of the papilla and by engorgement and 



DISEASES OF THE OPTIC NERVE. 369 

tortuosity of the central retinal veins; but this swelling 
and the engorgement of the retinal veins are much more 
marked in choked disc than in descending neuritis, and 
for this reason it is usually possible, with the ophthalmo- 
scope, to differentiate the two forms (Fig. 142) . In addi- 
tion to the engorgement of the veins and the swelling of 




Fig. 142. — Choked disc, or papillitis (Haab). 

the papilla, which latter is due to edema and inflamma- 
tory exudation as well as to hyperemia, and which, ex- 
tending somewhat into the retina, obliterates the usually 
well-defined margin of the disc, both types are com- 
monly attended by hemorrhages upon and around the 
papilla, and not infrequently by inflammatory changes 
in the neighboring portions of the retina. When these 
24 



370 



PREVALENT DISEASES OF THE EYE, 



changes in the retina are pronounced the condition is 
called neuro-retinitis. 
Choked Disc (Papillitis I. — In this type of intraocu- 




Fig. 143. — From a photo-micrograph by Dr. James Wallace of a section of a 
choked disc prepared bv Dr. William Thomson. 



lar neuritis, the supposed etiology of which has been 
referred to, and which, as has been said, is characterized 
bv great swelling ot the papilla and great engorgement 
of the retinal veins (Fig. 143), sight is often, and it mav 



DISEASES OF THE OPTIC NERVE. 37I 

be for a long time, insignificantly impaired, the impair- 
ment being very much less than the pronounced fundus 
changes would lead one to expect. Not infrequently 
an enlargement of the normal "blind spot" is the only 
visual disturbance observed, until finally atrophy of the 
nerve-fibers ensues, when, if this is complete, sight is 
entirely lost. Owing to this circumstance and the fur- 
ther fact that, except perhaps for a slight dilatation 
and sluggishness of the pupil, the eye exhibits no ex- 
ternal evidences of the serious malady with which it is 
afflicted, it often happens that the true condition is first 
discovered not by the oculist but by the physician con- 
cerned with affections of the brain and nervous system, 
whose advice is sought for the relief of headache or 
other symptoms pointing to intracranial disease. The 
process is a chronic one, often lasting for months, and, 
as has been intimated, it usually ends in atrophy of the 
nerve and loss of sight. 

The commonest cause of choked disc is intracranial 
tumor, though almost any coarse disease of the brain 
may give rise to it. The character of the tumor, 
whether malignant or benign or of syphilitic origin, 
and its size and location seem to have but little influence 
in determining the result, so far as the involvement of the 
optic nerve is concerned. Optic neuritis, and usually 
of the choked disc type, is present in from eighty to 
ninety per cent, of intracranial new-growths. It is 
obvious, therefore, that its existence, while it throws no 
light upon the location of the growth, is of great diag- 
nostic value in this class of cases, and that it should be 
sought for ophthalmoscopically whenever there is reason 
to suspect the presence of a brain tumor. 

Other conditions which may give rise to choked disc 
are meningitis, acute and chronic, — in children tuber- 



372 PREVALENT DISEASES OF THE EYE. 

culous meningitis especially, — abscess and softening of 
the brain, thrombosis of the sinuses, hydrocephalus, 
traumatic lesions of the head, the acute infectious 
diseases, such as scarlet fever, smallpox, measles, 
diphtheria, influenza, pneumonia, and typhoid fever; 
disturbances of nutrition, such as occur in nephritis, 
diabetes, disorders of menstruation, pregnancy, and the 
puerperal state; syphilis, either directly or through the 
development of gummata, meningitis or periostitis; and, 
finally, affections of the orbit — new-growths, periostitis, 
etc. When arising from pathological changes in the 
orbit choked disc is usually monolateral, but under 
other circumstances it is almost always bilateral. 

Descending optic neuritis, characterized, as has 
been said, by less marked swelling of the papilla, 
by decidedly less engorgement and tortuosity of the 
retinal veins, and, perhaps, by greater disposition to 
involvement of the retina, is distinctly a disease of in- 
tracranial origin. Its most common cause, probably, is 
basilar meningitis, especially that of tuberculous origin, 
which is usually accompanied by inflammation of the 
contiguous brain substance, though it may be produced 
by a tumor situated at the base of the brain, and which 
has given rise to a localized cerebritis. It commonly 
runs a less protracted course than the choked disc type 
of optic neuritis, and vision is sooner impaired. 

As to the ultimate outcome of the two conditions 
— choked disc and descending optic neuritis — the 
prognosis is much the same. When either, as is so 
often the case, is dependent upon incurable intracranial 
disease, or upon such irremediable affections as chronic 
nephritis, diabetes, and the like, it is thoroughly bad; 
but, on the other hand, when due to affections that are 
themselves amenable to treatment, such as syphilis, 



DISEASES OF THE OPTIC NERVE. T>1Z 

the acute infectious diseases, rheumatism, etc., it is 
more hopeful, and under such circumstances much may 
be accomplished by energetic and promptly employed 
remedial measures. 

Treatment. — This, of course, depends in large meas- 
ure upon the condition that has given rise to the neuritis. 
If it be consequent upon intracranial disease every effort 
should be made to combat this, and in exceptional in- 
stances radical operative procedures — the removal of 
a cerebral tumor, for example — may be demanded. 
Mercury, in liberal doses, and potassium iodid, heroically 
administered, are the constitutional remedies chiefly to 
be relied upon, not only because they may possibly 
exert a favorable influence upon the intracranial affec- 
tion, but because of their direct effect upon the neuritis. 
They should be employed the more persistently when- 
ever there is reason to believe that syphilis may be a 
factor, direct or indirect, in the causation of the neuritis; 
for under such circumstances much may be hoped for 
from their influence. Pilocarpin, so administered as to 
produce marked salivation and sweating, is another 
remedy which at times proves useful, while sodium 
salicylate in large doses may be beneficial, especially, 
but not solely, in cases of rheumatic origin. 

The urine should be examined in every case of 
optic neuritis, as this may afford important infor- 
mation as to its etiology and as to the line of 
treatment to be employed. The bowels should be 
regulated, any tendency to constipation being care- 
fully controlled, and from time to time an ener- 
getic purgative may be given with good effect. If 
the neuritis be dependent upon orbital disease this 
should receive appropriate treatment, operative or 
otherwise. From the application of remedies to the 



374 PREVALENT DISEASES OF THE EYE. 

eye itself little benefit is likely to result; it should, how- 
ever, be protected from undue exposure to bright light, 
and should be given as complete rest as possible. 
Prompt response to treatment is hardly to be expected, 
even in the more favorable cases. 

Retrobulbar Neuritis (Orbital Neuritis). — Two 
types of retrobulbar neuritis are recognized, an acute 
and a chronic form. They resemble each other chiefly 
in that in each the inflammation affects the orbital 
portion of the nerve, and that in each the papillo- 
macular fibers — those fibers which supply the macular 
region — are the ones first attacked. In each, too, if 
the process is not arrested, all of the nerve-bundles in 
time are involved, and ultimately undergo atrophy. 

Acute Retrobulbar Neuritis. — There are a va- 
riety of causes which seem to be capable of giving 
rise to this affection The most common are syphilis, 
rheumatism, gout, the exanthemata, influenza, sudden 
suppression of the menstrual flow, chilling of the surface 
of the body from exposure to wet and cold, and the 
ingestion of considerable quantities of methvlic or wood 
alcohol. It may also be secondary to other orbital dis- 
ease. It is usually unilateral, and the svmptoms which 
indicate its existence are rapid decline of central vision, 
moderate dilatation and sluggishness of the pupil in re- 
sponse to light, and not infrequently retrobulbar pain 
when the eye is turned in different directions or is 
pressed toward the apex of the orbit. 

As the nerve fibers which supplv that portion of the 
retina lying between the optic disc and the macula are 
those primarilv affected, the visual disturbance mani- 
fests itself at first in the form of a paracentral scotoma — 
a circumscribed area of impaired vision near to, and per- 
haps involving, the center of the visual field. At the 



DISEASES OF THE OPTIC NERVE. 375 

outset this impairment of vision may be slight, amount- 
ing only to inability to distinguish colors, but it may 
increase rapidly, so that within this area objects can no 
longer be distinguished; and, if the inflammation extends 
from the papillo-macular fibers to the rest of the nerve, 
a general disturbance of vision will ensue, which may 
eventuate in total loss of sight. 

The disease runs a much less protracted course than 
do the intraocular forms of neuritis, and the prognosis, 
as a rule, is less grave; still, the outcome is always uncer- 
tain, and permanent impairment of vision, especially 
a persistent central scotoma, may result. 

Treatment. — Potassium iodid, alone or in combination 
with biniodid of mercury, sodium salicylate, especially 
when the affection is of rheumatic origin, and, at a 
later stage, strychnin, are the remedies of greatest value. 
Local treatment, except perhaps the abstraction of blood 
by leeches, or the application of a blister to the forehead 
or temple, is of little efficacy. Complete rest of the 
eyes and their protection from bright light should, of 
course, be enjoined. 

Chronic Retrobulbar Neuritis (Toxic Ambly- 
opia). — This disease, as the subtitle indicates, is 
caused by certain toxic agents, which, acting usually 
for a considerable time upon the system, eventually 
induce a chronic, peripheral, interstitial inflammation 
of the optic nerve. As in the acute form of the disease, 
the papillo-macular fibers are the first to suffer. (See 
Plate IX.) The affection is commonly bilateral, and 
its outcome, unless the inflammatory process can be 
arrested, is blindness from atrophy of the optic nerves. 

The first complaint of the patient is of a "fogginess" 
of vision, as though he were seeing objects through a 
smoky atmosphere. A common accompanying symp- 



376 PREVALENT DISEASES OF THE EYE. 

torn is recurrent frontal headache. A characteristic 
early symptom, to be determined by a perimetric exam- 
ination, is a nearly central color scotoma — an area of 
red-green blindness extending from the fixation point 
to the normal blind spot. Any degree of impairment 
of central vision may be present, a visual acuteness of 
one-fourth to one-tenth normal being not unusual at 
the time medical advice is sought. The fact that the 
failure of sight is very gradual probably explains this 
singular circumstance. 

Although in exceptional instances the disease under 
consideration is produced by such agents as nitrobenzol 
(used in the manufacture of certain explosives), bi- 
sulphid of carbon (employed in vulcanizing rubber), 
arsenic, lead, iodoform, etc., it is usually caused bv 
tobacco or alcohol or, as is more often the case, by the 
combined action of the two. For this reason it is en- 
countered much more frequently in males than in 
females. The habitual smoker and the habitual dram- 
drinker are the ones in whom it is most likely to develop. 
In some instances it has been observed in persons whose 
employment compelled them to inhale air laden with 
tobacco dust, as in tobacco manufacturing establish- 
ments. It is rarely met with in persons under thirty-five 
years of age. 

Although the intraocular signs of chronic retrobulbar 
neuritis are not very marked or characteristic, the oph- 
thalmoscope is helpful in arriving at a diagnosis. In 
the early, the inflammatory, stage of the disease there 
is usually marked hyperemia of the optic disc. Later 
on, when the stage of atrophy is reached, the disc be- 
comes pale and perceptibly cupped, and the lamina 
cribrosa is seen with too great distinctness, these 
changes commonly being more marked in the lower 



PLATE IX. 



I'/.i/c I l;„,i>if-\. 








-( r„ y j. 







» 



Sja*" MI ** , * , ^ r - 



Sections of the Right Optic Nerve of Dr. G. E. de Schwetnitz's 
Case of Tobacco Amblyopia, Showing Degeneration of the Papil- 
lomacular bundle ; weigert's stain. 

Fig. i. — Longitudinal section of the posterior half of the right bulbus 
and five millimeters of the optic nerve. 

Figs. 2 and 3. — Transverse sections of the optic nerve, eight and 
thirteen millimeters, respectively, behind the globe. 

Figs. 4 and 5. — Transverse sections of the optic nerve in the region of 
the optic foramen. 

Fig. 6. — Transverse section of the nerve in the intracranial region. 



DISEASES OF THE OPTIC NERVE. ^JJ 

temporal quadrant, which corresponds with the situa- 
tion of the papillo-macular fibers. 

The prognosis, especially in the cases which are due 
to tobacco and alcohol, is not unfavorable, even when 
vision is greatly impaired, if the atrophic process has 
not already progressed too far. 

Treatment. — The most important feature of the treat- 
ment is the absolute withdrawal of the toxic agent which 
has provoked the neuritis. In the case of smokers and 
dram-drinkers total abstinence from the use of tobacco 
and alcohol must be insisted upon. In addition to this, 
and especially during the inflammatory stage, indicated 
by the hyperemic papilla, moderate doses (jj to Jj of a 
grain) of biniodid of mercury should be prescribed, and 
in combination with this strychnin should be given in 
ascending doses. There is no excuse, in my judgment, 
for administering the strychnin hypodermically, as 
some authorities advise. Beginning with a thirtieth of 
a grain, given three times a day, and directly after meals, 
the dose may be gradually increased, as tolerance is 
established, until finally it reaches five or six times this 
amount. It has not been my experience, in a single 
instance, to meet with the cumulative effect which some 
contend is liable to occur from the prolonged exhibition 
of this drug. 

Quinin Blindness. — As a result of the adminis- 
tration of heroic doses of quinin, and in susceptible in- 
dividuals of doses which could not be so regarded, pro- 
nounced impairment of vision, at times complete loss 
of sight, occasionally is produced. Investigation has 
shown that the visual disturbance, which is usually ac- 
companied by deafness and marked tinnitus, is due to 
excessive spasm of the vessels of the retina and optic 
nerve. The resulting ischemia, if it persists for a con- 



3J% PREVALENT DISEASES OF THE EYE. 

siderable time, may give rise to degeneration of the gan- 
glion cells and nerve-fibers of the retina and ultimately 
to an ascending atrophy of the optic nerve, as Ward 
Holden has pointed out. Fortunately, the outcome of 
these cases is usually not so serious, the blindness often 
proving to be transient, and normal vision being re- 
gained, it may be after a few hours, or, perhaps, not until 
the lapse of some days. While the blindness persists 
the pupils are widely dilated and non-responsive to light. 
Not infrequently the loss of sight is preceded by head- 
ache, unsteadiness of gait, and, in some instances, by 
visual hallucinations. 

Treatment consists in inhalations of nitrite of amyl 
and in the administration of nitroglycerin, to be followed 
by ascending doses of strychnin. The giving of quinin 
should, of course, be stopped at once. 

Atrophy of the Optic Nerve. — Two definite types 
of optic nerve atrophy are recognized — a primary, non- 
inflammatory atrophy, which is usually consequent 
upon spinal disease, and an atrophy consecutive to optic 
neuritis or retinitis. With the ophthalmoscope it is 
usually possible to distinguish these two forms, for 
although in each the optic disc is pale, or conspicuously 
white if the atrophy is advanced, there are present in the 
post-neuritic type certain definite signs of the precedent 
inflammation which are wanting in the primary type. 
Clinically the two forms differ in that while the prog- 
nosis is grave in each, it is more entirely hopeless in 
primary than it is in consecutive atrophy. The progress 
of the former also is slower, and in it both eyes are 
almost always involved, whereas the latter is not infre- 
quently unilateral. 

Primary, simple, or non-inflammatory atrophy 
of the Optic nerve is oftenest encountered in tabes 



DISEASES OF THE OPTIC NERVE. 379 

dorsalis; it is not uncommon also in the general paraly- 
sis of the insane, and it may be due to syphilis, 
venereal excesses, diabetes, or the toxic action of certain 
drugs. There is also a hereditary form, which occurs 
almost exclusively in males, and there is still another 
form which is produced by compression of the nerve — 
as by the growth of a tumor, periosteal thickening and 
the like — either within the cranium or within the orbit. 
As has been said, the affection is almost always bilateral, 
the cases in which only one eye is involved being usually 
those which are consequent upon orbital disease. 

Among the earliest symptoms are inability to dis- 
tinguish small objects — as, for example, the letters of a 
printed page — by subdued light, diminution or loss of 
color perception, and, as shown by the perimeter, con- 
centric, or perhaps quite irregular, contraction of the 
visual fields. Slowly the decline of vision progresses, 
until ultimately, it may be not until after many months, 
sight is completely lost. The failure of vision is ac- 
companied by expansion, exceptionally, in certain 
spinal affections, by contraction, of the pupil, and by its 
sluggish response, or complete lack of response, to light 
stimulation. Especially in cases of tabetic origin, the 
Argyll-Robertson symptom is observed — failure of the 
pupil to contract to light, but its prompt contraction 
when accommodation and convergence are called into 
play. 

The ophthalmoscopic signs of simple atrophy — and 
in no case of suspected optic nerve atrophy should an 
ophthalmoscopic examination be omitted — are very 
striking. The papilla, at first only slightly pale, grows 
progressively whiter as the nerve-fibers atrophy and the 
fine blood-vessels, which give to the normal papilla its 
pinkish color, disappear. At the same time its outlines 



380 PREVALENT DISEASES OF THE EYE. 

remain sharply defined, its surface becomes more or 
less markedly depressed, and the lamina cribrosa is 
seen with too great distinctness, and not over a limited 
area only, as when a deep physiological cup is present, 
but over the whole, or a considerable part, of the disc 
(Fig. 144). Accompanying these alterations in the 
nerve-head there is commonly some diminution in the 
caliber of the retinal arteries; but, apart from this, and 




Fig. 144. — Primary atrophy of the optic nerve (Haab). 

in striking contrast to what is observed in post-neuritic 
or post-retinitic atrophy, there are no other fundus 
changes — no thinning or heaping up of the retinal or 
choroidal pigment. In tabes, atrophy of the optic 
nerve is often an early symptom, making its appear- 
ance before the occurrence of the ataxia. It should, 
therefore, always be sought for whenever there is a 
suspicion of the existence of this affection. 



DISEASES OF THE OPTIC NERVE. 38 1 

Treatment is of but little avail, as may be inferred 
from what has been said as to the irremediableness of 
the affection. Strychnin, in increasing doses, should be 
given a thorough trial, and if there is a history of lues 
potassium iodid should be prescribed in full doses. 
Galvanism and massage, which some commend, are 
of little or no value. 

Consecutive Atrophy of the Optic Nerve (In- 
flammatory Atrophy). — This type of degeneration 
of the nerve may follow any one of the several forms 
of optic neuritis, or may be secondary to uncontrolled 
retinitis; it may also be consequent upon embolism or 
thrombosis of the central artery of the retina or throm- 
bosis of the central vein. It is especially prone to occur 
after the so-called intraocular forms of neuritis, and is 
less common after retrobulbar neuritis. 

The subjective symptoms are much the same as in 
primary atrophy, though the failure of sight is usually 
more rapid, and the affection is less constantly bilateral. 
The pupil is dilated and responds sluggishly, or not at 
all, to light. Apart from this, the eye exhibits no 
external signs of disease. 

The diagnosis is to be definitely established only by 
an ophthalmoscopic examination. The fundus changes 
differ appreciably from those seen in simple atrophy. 
The papilla is white, but its margins are ill-defined, 
and, owing to the presence of newly formed connective 
tissue resulting from the precedent inflammation, it 
lacks the translucency observed in primary atrophy, and 
for this reason the lamina cribrosa is not seen. The 
indistinctness of the disc-margin is in part due to this 
same cause and in part to pigment changes in the ad- 
jacent retina. The retinal vessels upon and in the 
neighborhood of the papilla are frequently bordered 



382 PREVALENT DISEASES OF THE EYE. 

by white streaks, due to thickening of their lymph- 
sheaths. The arteries are diminished in size, the veins 
for a considerable time often distended and tortuous. 
When the atrophy is consequent upon retinitis, the pig- 
ment and other changes usually left by this condition 
are found disseminated over the eye-ground, and the 
retinal vessels, veins as well as arteries, are commonly 
much diminished in caliber. 

The prognosis in consecutive atrophy depends in 
large measure upon the stage which the atrophic process 
has reached at the time the case comes under observa- 
tion and upon the nature of the affection primarily 
responsible for it. If the inflammatory process is still 
active, and the nerve-fibers are suffering from the com- 
pression of exudates the absorption of which it may 
be possible to bring about, much may be hoped for 
from energetic treatment. On the other hand, if the 
case is not seen until a considerably later period, when 
the inflammation is a thing of the past, and the degen- 
eration of the nerve is advanced, the outlook is wholly 
unpromising. It is most unpromising also when the 
primary affection of the nerve has been caused by 
serious intracranial disease or by such intractable 
maladies as chronic nephritis, diabetes, etc., or has fol- 
lowed degeneration or severe inflammation of the retina. 

Treatment. — This must depend largely upon the 
conditions existing at the time the case is seen. Po- 
tassium iodid and mercury are the remedies to be .relied 
upon to promote the absorption of exudates, and relieve 
the nerve fibers from compression, and therefore are of 
greatest value when given at an early stage of the affec- 
tion. In addition, strychnin, in increasing doses, is 
indicated, at this stage as well as at a later period, when 
it is, in fact, our only reliance. 



DISEASES OF THE OPTIC NERVE. 383 

Hemianopsia (Hemiopia). — Hemianopsia or half- 
blindness, a serious disturbance of vision, sudden in 
onset, involving both eyes, and of most unfavorable 
prognosis, finds its explanation in the semi-decussation 
of the optic nerves. When the nerve-fibers of each optic 
tract reach the chiasm, it will be remembered, they sep- 
arate into two bundles — an outer bundle which proceeds 
to the eye of the same side, and an inner bundle which 
crosses in the chiasm and proceeds to the opposite eye. It 
will be remembered also that the non-decussating fibers 
supply the outer or temporal half of the retina of the 
eye to which they go, and that the decussating fibers sup- 
ply the inner or nasal half. As a consequence of this, it 
is evident that the fibers coming from the right side of the 
brain, and forming the right optic tract, supply the right 
half of the retina of each eye, that is to say, the temporal 
half of the retina of the right eye and the nasal half of 
that of the left eye; while the conditions are reversed 
as to the fibers coming from the left side of the brain. 
From this it is further evident that a lesion, for example, 
of the right optic tract, or the visual centers of the 
right half of the brain with which it is in relation, will 
destroy the perceptive power of the right half of each 
retina, causing left-sided blindness or loss of the left 
half of the visual field of each eye; that a lesion which 
affects the decussating fibers only will cause blindness of 
theinner or nasal half of each retina, with loss of the outer 
or temporal visual field of each eye, and that one which 
involves only the non-decussating fibers will affect the 
outer half of each retina and result in blindness of both 
nasal fields. A further possibility is that the nerve- 
fibers supplying either the upper or the lower half of each 
retina may be destroyed, and, as a consequence, that 



384 



PREVALENT DISEASES OF THE EYE, 



the lower or upper half, as the case may be, of the visual 
field of each eye may be lost. 

All of these forms of hemianopsia — which a study of 
the accompanying illustration (Fig. 145) will make more 



Musadus rectus 
ex£er7iu*s. 



Musadas rectus 
externus. 




XoiC OccipvtaZus 

Fig. 145. — Scheme of the optic tracts (after von Monakow). 



easy of comprehension — are met with; but the two last- 
described, known respectively as binasal hemianopsia 
and horizontal hemianopsia, for obvious reasons — be- 
cause a lesion which shall affect the non-decussating 



DISEASES OF THE OPTIC NERVE. 385 

fibers at each extremity of the chiasm, without involving 
the decussating fibers lving between them, or one which 
shall destrov onlv the fibers lying close to the upper or 
lower surface of the chiasm, permitting the others to es- 
cape, must necessarilv be ot rare occurrence — are very 
uncommon. On the other hand, the two first-mentioned 
forms — that in which the right, or it mav be the left, 
half of the visual field of each eve is lost, known as 
homonymous lateral hemianopsia, and that in which both 
temporal fields are lost, known as bitemporal hemian- 
opsia, — are more frequently encountered, and demand 
fuller consideration. 

Homonymous Lateral Hemianopsia, — This variety 
of hemianopsia, in which there is loss of the right 
or left half of each visual field, is the one oftenest 
met with. It mav be caused bv a lesion of either cor- 
tical visual center or bv one which produces a break 
in the visual tract anywhere between this center and the 
optic chiasm, that is, in the optic radiations, in the pri- 
mary visual ganglia, or in the optic tract itself. Among 
the conditions apt to produce such a lesion mav be 
mentioned hemorrhage, embolism, softening, abscess, 
intracranial syphilis, and the pressure of a tumor. 

The visual disturbance, which mav be preceded bv 
headache and accompanied bv giddiness and nausea, 
is commonly sudden in onset, and is at times attended 
by other evidences of serious brain injury, such as hemi- 
plegia, aphasia, etc. The loss of vision in the affected 
half of the field is usuallv complete; but fortunately 
the macular region nearly always escapes serious in- 
volvement, and good central vision is retained. This 
is due to the fact — doubtless a result of the action of the 
law of the survival of the fittest — that this most essential 
and most highly specialized portion of the retina is 



386 PREVALENT DISEASES OF THE EYE. 

supplied by fibers from both sides of the brain. Be- 
cause of the one-sided character of the blindness, the 
patient frequently imagines that one eye only is affected, 
and is much surprised when made aware of the true con- 
dition. At first he experiences much inconvenience 
from the curtailment of his field of vision, but in time 
he becomes less conscious of the defect. As might be 
supposed, the affection is more common in advanced 
life, when the walls of the blood-vessels are undergoing 
degenerative changes. For some time after the onset 
of hemianopsia the ophthalmoscope shows no alter- 
ation in the papilla, but later evidences of partial atro- 
phy may make their appearance. 

Attacks of transient hemianopsia, lasting usually for 
but a few moments, and of very different import from 
the serious affection under consideration, are not un- 
common. They are doubtless due to some temporary 
disturbance in the circulation of the visual centers, and, 
in my experience, are oftenest brought on by eye-strain 
from refractive or muscular faults. 

Bitemporal Hemianopsia. — This form of half-vision, 
of much less frequent occurrence than the one just de- 
scribed, is produced by a lesion involving the central 
portion of the chiasm, and injuring the decussating 
fibers only. It may be the result of hemorrhage, aneu- 
rism, syphilis, of a tumor, or of a fracture of the base 
of the skull. It also occurs in acromegaly as a conse- 
quence of enlargement of the pituitarv body. The dis- 
turbance of vision is very annoying because of the great 
circumscription of the lateral fields. 

In bitemporal as well as in binasal hemianopsia the 
prognosis is somewhat more favorable than in the ho- 
monymous form. Homonymous hemianopsia has little 
or no localizing value, as is evident from what has been 



DISEASES OF THE OPTIC NERVE. 387 

said as to the various conditions which may give rise to 
it; but the bitemporal and binasal forms have, since 
they indicate that the lesion is in the neighborhood of 
the chiasm. The importance in all cases of cerebral 
disease of measuring the visual fields, to determine 
whether or not hemianopsia is present, is manifest. 

The treatment of the several varieties of hemianopsia 
is usuallv without avail. The prognosis, as a rule, is 
more promising in the cases of syphilitic origin. Po- 
tassium iodid and mercury are the remedial agents from 
which most is to be hoped. 



CHAPTER XL 

ANOMALIES OF REFRACTION AND ACCOMMO- 
DATION. 

ANOMALIES OF REFRACTION. 
It is not the purpose of this chapter to encourage the 
general practitioner to undertake the determination and 
correction of the refractive anomalies of the eye, or to 
teach him how to do this. On the contrary, one of its 
purposes, at least, is to impress upon him, what so 
many physicians fail to realize, that there is no branch 
of ophthalmic practice which more imperatively de- 
mands the skill and training of the specialist than does 
this matter of the measurement and correction of the 
refractive errors and muscular faults of the eyes. There 
are, indeed, few misconceptions which call for more vig- 
orous combating than the belief, so common among 
medical practitioners who have paid but little attention 
to diseases of the eyes, that the adjustment of glasses is a 
trivial matter which may be undertaken by any physi- 
cian who may have provided himself with test-cards and 
a trial case, or may be safely left to the hap-hazard 
methods of the nearest vender of spectacles, or to the 
jeweler's clerk who, after a few weeks of instruction in 
an "optical college," announces himself as an "exam- 
ining, " or an " ophthalmic," optician. How much harm 
the community suffers from the pretentious ignorance 
of such tyros it would be difficult to estimate. Let the 
general practitioner but bear in mind that the vender 
of spectacles — the optician — has a knowledge of the eye 

388 



ANOMALIES OF REFRACTION. 389 

and its diseases about equivalent to that which the ven- 
der of drugs — the apothecary — has of general medicine, 
and he will not be so apt to fall into the error which I 
have tried to emphasize. Not only the welfare of the 
eye, it should be borne in mind, but in many instances 
the general well-being of the individual hinges upon 
the accuracy with which these optical and muscular 
faults are corrected. 

How important a role errors of refraction play in the 
causation of many serious diseases of the eye few who 
have not made a special study of the subject realize. 
Frequent reference has already been made to this fact, 
and in treating of the etiology of cataract, of glaucoma, 
of choroido-retinitis, of chronic conjunctivitis, and of 
blepharitis marginalis much stress, it will be recalled, 
was laid upon the important influence exerted by accom- 
modative strain in the production of these diseases. 
From my own observation, I am well satisfied that even 
such affections as albuminuric and diabetic retinitis, 
syphilitic choroido-retinitis, and the inflammatory pro- 
cesses of the eye dependent upon a rheumatic diathesis 
are, at least, unfavorably influenced, if not in some in- 
stances actually precipitated, by the strain caused by 
uncorrected refractive and muscular anomalies.* That 
not only strabismus but many less obvious disturbances 
in the ocular muscle-balance are largely dependent upon 
errors of refraction is, of course, well established. 

As to the importance of the role played by eye-strain 
in the production of other disorders than those of the eye 

*This statement may seem extravagant; but it will not be denied 
that in such disorders it is the tissues the resisting powers of which 
are poorest that are most apt to suffer. And, unquestionably, this 
is the condition of the internal tunics of an eye which, as a result of 
long-continued accommodative strain, are already in a state border- 
ing upon inflammation. 



39° PREVALENT DISEASES OF THE EYE. 

itself there can be no question; though it must be ad- 
mitted that, as to this, there has been much exaggeration. 
The claim, seriously put forward, that sterility, men- 
strual disorders, habitual constipation, epilepsy, etc., 
are frequently due to refractive errors, and may be 
cured by their correction, is, of course, absurd; but, 
on the other hand, there can be no doubt that such errors 




Fig. 146. — Types of spherical lenses prescribed in ametropia and pres- 
byopia: 1, Biconvex lens; 2, plano-convex lens; 3, concavo-convex lens, 
convergent meniscus; 4, biconcave lens; 5, plano-concave lens; 6, convexo- 
concave lens, divergent meniscus (de Schweinitz). 

are a common cause of headache, of neurasthenia, of 
vertigo, of insomnia, of somnolency, and of disturbance 
of mental concentration; that they are a less frequent 
cause of nausea, indigestion, tinnitus aurium, and 
chorea, especially of the facial muscles; and that, excep- 
tionally, they exert a by no means unimportant influ- 
ence upon epilepsy. 



ANOMALIES OF REFRACTION. 39I 

Before describing the refractive errors, it will not be 
amiss to speak of some of the prevalent misconceptions 
regarding these errors and concerning the indications 
for glasses and their influence upon sight (Fig. 146). 

In the first place, it is a mistake to suppose that errors 
of refraction — which are really faults in the conforma- 
tion of the eye — may be "outgrown,'' or may be gotten 
rid of by any therapeutic procedure, such as prolonged 
rest, systematic exercise of the eyes, massage, etc., 
and, as a corollary of this, that the wearing of glasses 
should be regarded as a dernier ressort. 

In the next place, it is as great a mistake to imagine 
that glasses are injurious to the eyes, that they "weaken 
the sight," as the common expression is, and that if their 
use is begun in early life a time may come when it will not 
be possible to find lenses that will afford the needed help. 
If glasses really are needed, the eyes soon learn to accept 
the help which they give, and, of necessity, become de- 
pendent upon this help; but so far from injuring the 
eyes or "weakening the sight," the effect, of course, is 
exactly the reverse. Furthermore, though glasses of 
considerable strength be prescribed, as is often neces- 
sary, for children not yet in their "teens," there need be 
no fear, though they live to be octogenarians, that the 
required lenses can not be easily supplied. In a word, 
the popular prejudice against the wearing of glasses, 
and especially against their use by young persons, is 
entirely without warrant. Unquestionably, from a 
cosmetic point of view objection may be urged against 
their use; but this, of necessity, must give way to con- 
siderations of greater weight. 

Again, it should be remembered that glasses are not 
given solely with a view to making vision more acute. 
As a matter of fact, in many instances, especially in 



392 PREVALENT DISEASES OF THE EYE. 

earlv life, there may be urgent need for them, and yet 
normal acuteness of vision, for both near and distant 
objects, may exist. Under such circumstances, and 
this applies, of course, to many cases in which, besides, 
they do render vision more acute, thev are demanded for 
the purpose of relieving the strain which the optical 
error imposes upon the accommodative apparatus. In- 
deed, the very fact that young eyes, in spite of the exist- 
ence of marked refractive errors, often do see sharply is 
evidence of the great tension under which they perform 
their office. It may be well to add that though glasses 
unquestionably tend to prevent the increase of certain 
refractive errors — mvopia especiallv — it is not to be 
expected that they will cure the optical defect, for which 
thev are prescribed. For this reason, the hope can 
seldom be held out that after a time the eyes will not 
need their assistance. In exceptional instances this may 
happen, as, for example, in low grades of hypermetropia 
or astigmatism, when the asthenopic symptoms have 
manifested themselves for the first time after an illness 
which has lowered the general tone of the system; 
but such instances, it is well to remember, are distinctly 
exceptional. 

Finally, it should be stated that not every eye needing 
the help of glasses makes a direct appeal for their aid. 
Not infrequently, when the remote consequences of eye- 
strain are pronounced, there may be little or no com- 
plaint of the eves themselves. Therefore one should 
not be too ready to conclude that persistent headache, 
obscure neurasthenic symptoms, etc., can not be due 
to eye-strain, because there is little or no asthenopia. 
In illustration of this, a case may be mentioned which 
came under my observation not long since. A young 
woman, who was unconscious of anything being amiss 



ANOMALIES OF REFRACTION. 393 

with her eves, frequently awakened in the middle of 
the night with attacks of pronounced vertigo. Her 
physician, not being able to discover a cause for these 
attacks or a means of relieving them, thought of the 
possibility of their being dependent upon eye-strain, 
and sent her to me for advice. A moderate amount of 
astigmatism was discovered, and correcting glasses 
were prescribed, with some misgivings as to the result; 
but after they had been worn a very short time the ver- 
tiginous attacks ceased. 

Emmetropia. — In order to a proper understanding of 
the refractive errors of the eve one should have a clear 
conception of what constitutes an optically normal, or, 




Fig. 147. — Diagram of emmetropic eye. 

as it is called, an emmetropic eve. An eve is said to be 
emmetropic when it is so constructed, when the focal 
length of its system of lenses with reference to the dis- 
tance between the cornea and the retina is such, that, 
with the accommodative apparatus at rest, parallel rays 
of light, those coming from distant objects, are brought 
to a focus exactly upon the retina (Fig. 147). In such an 
eye, it will be seen, accommodative effort is required 
only when near objects, the light from which reaches the 
eve in divergent pencils, are regarded, since sharp im- 
ages of distant objects are projected upon the retina 
without action upon the part of the ciliary muscle. An 
emmetropic eye, it should be added, is not necessarily a 



394 PREVALENT DISEASES OF THE EYE. 

sharp-seeing eye; indeed, it may be blind, for example, 
from atrophy of the optic nerve; but, however this may 
be, it is at all events one that is normal from the optical 
point of view. 

Ametropia. — This term, which is opposed to em- 
metropia, denotes a departure from the normal in the 
optical construction of the eye. If from any fault in the 
conformation of the eye sharp images of distant ob- 
jects are not formed upon the retina, or are so formed 
only by an effort of accommodation, such an eye is ame- 
tropic. The term is a general one, and under it are in- 
cluded all the optical errors, all the refractive faults, of 
the eye. If, for example, the lens system has an abnor- 
mally short focal length, while the eyeball is of normal 
dimensions, or if the focal length of the lens system is 
normal, while the eyeball is elongated in its antero-pos- 
terior diameter, that form of ametropia which is known 
as myopia, or short-sightedness, results. If, on the con- 
trary, the focal length of the lens system is longer than 
it should be, without a corresponding elongation of the 
eyeball, or if the eye is preternaturally flat, without a 
compensating increase of its refractive power, there will 
result the type of ametropia known as hypermetropia, 
or far-sightedness. If, again, there is a lack of sym- 
metry in the curvature of the cornea or the lens, or if the 
latter sets obliquely with reference to the visual axis, so 
that the rays of light entering the eye are not focused 
accurately at any point, we shall have still another 
form of ametropia, which we call astigmatism. 

Each of these refractive faults, which are of common 
occurrence, and which in certain important respects 
differ radically in their essential nature, in their mode 
of origin, and in their clinical course, has its character- 
istic shortcomings, which will be considered presently. 



ANOMALIES OF REFRACTION. 395 

Hypermetropia (Far-sightedness). — This type 
of refractive error, which very generally is of con- 
genital origin, is the most prevalent of all the optical 
defects of the eye. Indeed, it is so prevalent that it is a 
question whether the normal eye is not one that is 
slightly hypermetropic — that is, when its accommoda- 
tion is paralyzed by a cycloplegic — rather than exactly 
emmetropic. It goes without saying, therefore, that 
the very low grades of hypermetropia are, as a rule, of 
little moment, and seldom require correction. 

The fault of the hypermetropic eye is that it is in- 
capable of focusing upon the retina even parallel rays of 
light, without an effort of accommodation. The out- 
come of this is that so long as the eyes are in use the 
ciliary muscle is never at rest. But this is not the whole 
task imposed upon the hypermetropic eye. When it is 
employed in near vision, its accommodative apparatus 
must do double duty; its ciliary muscle must do what is 
required of the ciliary muscle of the emmetropic eye 
plus the effort which it necessarily puts forth to secure 
clear distant vision. Whether, under such circum- 
stances, the muscle must perform only considerably 
more work than is required of it under normal con- 
ditions, or twice or three times as much, depends upon 
the grade of the hypermetropia. Indeed, if the refrac- 
tive fault is excessive, and the same is true with lower 
degrees of hypermetropia when the power of accommo- 
dation has been partly lost through advancing age, it 
may prove unequal to the task imposed upon it, and 
as a result there will be indistinctness of vision for both 
far and near objects. Such a condition is known as 
absolute or non-facultative hypermetropia, while that in 
which clear vision is obtained through the action of the 
ciliary muscle is denominated facultative hypermetropia. 



396 PREVALENT DISEASES OF THE EYE. 

It is this ever-present strain upon the accommodative 
apparatus, greatly increased when the eyes are em- 
ployed in near vision, that gives rise to the asthenopia, 
headache, blepharitis marginalis, and the intermittent 
indistinctness of vision which are so frequently observed 
in hypermetropia of considerable degree. And it is by 
relieving this strain, by doing for the eyes what they 
strive to do for themselves at such cost, that glasses 
afford in this condition the complete relief they in- 
variably do. 

But there is still another difficulty with which the 
hypermetrope has to contend. In emmetropia there is 
a constant harmony between the effort of accommoda- 
tion and the effort of convergence of the visual axes, 
between the stimulus to action sent by the brain to the 
ciliary muscles and to the internal recti muscles. In 
distant vision both sets of muscles are completely re- 
laxed; in near vision both act in unison, a convergence 
for twelve inches, as in reading, for example, being ac- 
companied by a corresponding accommodative effort. 
In hypermetropia this harmony is radically disturbed — 
accommodation is always and necessarily in excess of 
convergence. In regarding distant objects, if clear 
vision is to be had, the ciliary muscles, as has been ex- 
plained, must act, while, if binocular vision is to be 
maintained, the internal recti muscle must remain qui- 
escent. In near vision the difficulty is the same, the 
ciliary muscles must put forth a much greater effort 
than is required of the interni. In a word, the effort 
to annul the normal relation between accommodation 
and convergence, to secure sharp vision and at the same 
time to maintain binocular fixation, is one of the hyper- 
metrope's most trying tasks. 

It is matter for little surprise, then, that the hy- 



ANOMALIES OF REFRACTION. 397 

permetrope should elect, not infrequently, to rid him- 
self of this task by a sacrifice of binocular vision; that, 
in order to restore the harmony between accommodation 
and convergence, he should permit one eye to squint. 
In his disposition to do this is to be found the explana- 
tion of the occurrence of convergent strabismus in hyper- 
metropia. As, however, many hypermetropes do not 
squint, it is manifest that there are other factors which 
influence the development of this fault. Among those 
tending to favor its occurrence may be mentioned insuf- 
ficiency of the external recti muscles and subnormal ac- 
commodative power; while it is manifest that insuffici- 
ency of the internal recti muscles and a power of accom- 
modation above the normal must have the contrary 
effect. Still, beyond question, by far the most potent 
factor in the causation of non-paralytic convergent 
squint, as Donders taught us, is hypermetropia, and for 
the reasons just set forth. 

It has been stated already that hypermetropia is 
nearly always a congenital anomaly, and that it consists 
either in an abnormal flatness of the eyeball or in a lack 
of refractive power in the lens svstem of the eye. The 
first-mentioned type, in which the antero-posterior axis 
of the eye is shorter than it should be, is the more com- 
mon form, and is known as axial hypermetropia (Fig. 
148). The type in which there is a lack of power in the 
refractive media, the cornea or lens, or both, being less 
convex than normal, is known as curvature hyperme- 
tropia, and is not only less common but is less uniformly 
congenital in origin, since it may be acquired through 
flattening of the cornea consequent upon inflammation, 
especially inflammation attended by loss of tissue. 

Congenital hypermetropia, it should be clearly under- 
stood, is not a pathological condition; it is simply a 



39$ PREVALENT DISEASES OF THE EYE. 

fault, often an inherited fault, in the conformation of the 
eye. It is also a fault which does not increase in degree; 
indeed, in early life, it often diminishes appreciably, but 
if it be considerable in amount its disappearance is not 
to be looked for. 

The ill consequences of hypermetropia, if the defect is 
of high grade, manifest themselves very early in life, as 
soon, indeed, as the child begins to use the eyes in re- 
garding small objects, as in looking at picture books or 
in learning to read. There is usually no complaint of 
the eyes, but it is S£en that the child has difficulty in dis- 




Fig. 148. — Diagram of axial hypermetropia. 

tinguishing small letters, and it is at this time that the 
squint, if it is to occur, is apt to develop. 

If the hypermetropia be non-facultative, if it be of so 
high a degree that sharp vision can not be maintained 
even by the greatest effort which the accommodation 
can put forth, the condition frequently simulates, and is 
mistaken for, myopia of high grade. The child holds 
the printed page very close to the eyes, since in this way 
a considerably larger retinal image is obtained, which 
more than offsets the increased blurring. If the defect 
be less pronounced, it may give rise to no inconvenience 
until the child is old enough to spend more time in 
study, when the appearance of asthenopia, headache, 
and, not improbably blepharitis, may be looked for. 



ANOMALIES OF REFRACTION. 399 

If of still lower grade, its existence may be unsuspected 
until, with the failure of accommodation consequent 
upon increasing years, it manifests itself through un- 
comfortable and defective near vision and through the 
need, at an exceptionally early age, of presbyopic 
glasses. 

Treatment. — It is evident, from what has already been 
said, that the whole treatment of hypermetropia is com- 
prised in the careful adjustment of glasses. With suit- 
able glasses the hypermetropic eye is relieved of all 
strain, and is capable of doing the work which the nor- 




Fig. 149. — Correction of hypermetropia by a convex glass. The lens L 
gives to parallel rays a convergence toward the point R f ; they will conse- 
quently be united upon the retina R without an effort of accommodation 
(de Schweinitz). 



mal eye does without assistance (Fig. 149). There 
need be no fear of ill consequences, therefore, in per- 
mitting the young hypermetrope, with his refractive 
error corrected, to pursue his studies as others do, or to 
adopt any vocation in life that may be thought desir- 
able. 

Whether he should be required to wear the glasses 
constantly, in far as well as in near vision, will depend 
largely upon the degree of the refractive fault, but in no 
small measure, also, upon his power of accommodation 
and upon the relative strength of the external and inter- 



400 PREVALENT DISEASES OF THE EYE. 

nal recti muscles. Theoretically, it would appear that 
the glasses should be worn constantly; but, practically, if 
the fault is not too pronounced, complete relief is often 
obtained by their use in near vision only. It follows that 
in determining the course to be pursued the muscle bal- 
ance for both far and near vision should be tested with 
the same care as the refractive error. The same consid- 
erations should influence one also in decidmg upon the 
strength of the glasses to be prescribed in any particular 
case. If the accommodation is active, and if the exter- 
nal recti muscles are relatively strong as compared with 
the internal recti, a very considerable part of the hyper- 
metropia may be left uncorrected; while, on the other 
hand, if the power of accommodation is poor and the 
external recti muscles relatively weak, glasses which 
give full or nearly full correction may be called for to 
insure complete relief. 

The practice followed, especially in this country, by 
many distinguished oculists of prescribing glasses which 
correct the total refractive error as revealed by a cyclo- 
plegic, without regard to the muscle balance, or, in other 
words, without reference to the ability of the eyes to help 
themselves, is, in my judgment, unwarrantable, since it 
not only fails to take account of the fact that a low de- 
gree of hypermetropia is hardly to be regarded as an 
abnormal condition, but, by giving the eyes more help 
than is called for, it disturbs too radically the established 
relation between accommodation and convergence, and 
thus substitutes for a difficulty of one sort a difficulty of 
another sort, which is nearly as intolerable. Moreover, 
it is objectionable because it renders the eyes more abso- 
lutely helpless, more completely dependent upon glasses, 
than is necessary. 

The older practice of correcting only that part of 



ANOMALIES OF REFRACTION. 4OI 

the hypermetropia which is manifest,* that is to say, 
the part which can be made evident without the em- 
ployment of a cycloplegic, provided this affords a normal 
muscle-balance in both distant and near vision, I can not 
but regard as a much more rational procedure. Not to 
be misunderstood, it may be well to add that it is to the 
considerably greater amount of hypermetropia that can 
be rendered manifest by painstaking binocular testing, 
and not to the less amount discoverable when the eyes 
are tested separately, that reference is had in this state- 
ment. Before resort to the binocular test the mani- 
fest fault of each eye should, of course, be carefully 
determined. 

With the gradual failure of accommodation that 
comes with increasing age the ill consequences of un- 
corrected hypermetropia become more and more pro- 
nounced. Thus it happens that a hypermetropia 
which has caused no inconvenience in childhood may 
become very troublesome with the passing of youth; 
for it must be remembered that the power of accommo- 
dation begins to decline very early in life, and that even 
a child ten or fifteen years of age has already lost a part 
of the ability to focus the eyes which it possessed when 
it was several years younger. From this it follows, 
other things being equal, that the need for glasses in- 
creases with the age of the hypermetrope, and that as 
he grows older he will not only require a fuller correction, 
but will more surely need to wear glasses in far as well 
as in near vision. This increasing dependence upon 
glasses need give rise to no anxiety for the future, how- 
ever; for, with suitable lenses, his eyes will continue to 

* The manifest hypermetropia is indicated by the strongest convex 
glass with which sharp distant vision can be maintained, without, of 
course, a cycloplegic being employed. 
26 



402 PREVALENT DISEASES OF THE EYE. 

serve him as well as though they had from the first been 
free from refractive fault. If, however, his error of re- 
fraction has not been recognized, or if, having been ad- 
vised to wear glasses, as not infrequently happens, he 
has disregarded the advice, it will be matter for little sur- 
prise if the years of strain to which his eyes have been 
subjected should sooner or later give rise to serious 
consequences, such as choroido-retinitis or, possibly, 
glaucoma or cataract. 

From what has been said as to the manner in which 
convergent squint arises in hypermetropia, it is evident 
that we have in glasses a very efficient means of pre- 
venting this deformity, and, in some instances, even of 
correcting it after it has become established. Indeed, 
it is safe to say that it might be prevented in almost 
every instance, if the refractive error could be corrected 
soon enough. The practical difficulty in the way of 
doing this is the very early age — when the wearing of 
glasses is almost out of the question — at which the squint 
commonly develops. Still, it is surprising how little 
difficulty is experienced in inducing a child that is de- 
cidedly hypermetropic, though it may be only three or 
four years old, to wear glasses; for the relief they afford 
is so pronounced that even so young a child soon appre- 
ciates it, and, instead of objecting to them, actually pre- 
fers to have them on. 

As to the possibility of correcting a convergent squint 
by glasses alone, without resort to operation, it may be 
said that this can be done always, if the case is seen before 
the habit has become firmly fixed, that is to say, during 
the stage when the squint is inconstant, is as yet periodic 
in character; and it is to be remembered that all cases of 
non-paralytic squint pass through such a stage, unless, 
indeed, as sometimes happens, the fault continues in- 



ANOMALIES OF REFRACTION. 403 

definitely to be periodic. As it falls to the lot of the gen- 
eral practitioner much oftener than to the specialist to 
see these cases during the formative stage of the squint, 
the responsibility which devolves upon him under the 
circumstances, and the great value of the advice which 
he is in a position to give, can not be too strongly em- 
phasized. 

Before dismissing the subject of the treatment of 
hvpermetropia it remains only to observe that, more 
often than not, hypermetropia is complicated by the 
coexistence of astigmatism, and that in view of this and 
of the fact, to which reference has already been made, 
that a clear comprehension of the muscular anomalies 
of the eyes and of the influence which glasses exert upon 
them is essential to the proper correction of this refrac- 
tive fault, it is evident that the treatment of hvperme- 
tropia is a matter to be undertaken only by the physician 
who has had especial training and experience. 

Myopia (Short-sightedness, Near-sightedness). 
— This defect is much less common than hypermetropia, 
from which it differs in several essential respects. In 
the first place, unlike hvpermetropia, it is nearly always 
an acquired, seldom a congenital, fault. In the next 
place, it is a fault which is commonly progressive; and, 
in the third place, it is usually accompanied by, indeed 
is dependent upon, a pathological condition of the eye. 
As is hypermetropia, inheritance often plays in myopia 
an important role; but it is not the defect itself that is 
transmitted from one generation to another, but rather 
a predisposition to its development. 

The essential fault in mvopia is that rays of light en- 
tering the eve from distant objects are brought to a focus 
not upon the retina, as they should be, but in front of it. 
This results either from the antero-posterior axis of the 



404 PREVALENT DISEASES OF THE EYE. 

eye being abnormally long or from an excess of refractive 
power in the lens system of the eye. The first-mentioned 
type is known as axial myopia (Fig. 150); the second, 
as curvature myopia. Axial myopia is the more common 
type and is very generally due to a yielding of the eyeball 
at its posterior pole, to the development, as it is called, 
of a posterior staphyloma. The sclerotic coat in the 
region of the macula and optic nerve entrance is incap- 
able of resisting the intraocular pressure and, being 
unsupported here, as it is laterally, by the recti muscles, 
becomes distended and thinned. The choroid and 
retina also participate in the staphylomatous process, and 
in myopia of high grade usually exhibit, ophthalmo- 




Fig. 150. — Diagram of axial myopia. 

scopically, marked signs of inflammation and degenera- 
tion. (See Fig. 132.) It is this insufficiency of the 
sclera, this disposition to the development of posterior 
staphyloma, that is inherited, and it is this that accounts 
for the family tendency to myopia often observed. 

Much less frequently axial myopia is the result of a 
gradual enlargement of the eyeball, of a general yielding 
of the sclera and cornea, such as occurs in the glaucoma 
of youth. 

In curvature myopia, which, like axial myopia, is com- 
monly an acquired condition, the cornea is usually the 
seat of the fault. As a result of inflammation or injury 
or in consequence of some inherent insufficiency the 



ANOMALIES OF REFRACTION. 4O5 

cornea becomes abnormally convex. In the condition 
known as conical cornea (see Fig. 102) we have one of 
the most striking examples of curvature myopia, which 
is often excessive in amount. Another type of curvature 
myopia is produced by an increase in the convexity of 
the lens, such as is frequently observed in the incipient 
stage of cataract, or by the lens, from any cause, assum- 
ing a position farther from the retina than it normally 
occupies. 

Axial myopia, being the type of near-sightedness 
usually encountered, calls for fuller consideration. 

While the inherited disposition to the development of 
posterior staphyloma unquestionably plays an impor- 
tant role in the causation of axial myopia, and in my 
opinion deserves greater consideration than is usually 
accorded it by recent authors, there are other etiological 
factors which are hardly less significant. Among the 
most important of these, unquestionably, are uncor- 
rected astigmatism and unrecognized anomalies of the 
ocular muscles. 

In their descriptions of the causes of myopia the use of 
the eyes in near vision — as in reading, writing, sewing 
and the like — is usually given more prominence by 
writers, it seems to me, than it deserves; for if this, of 
itself, were sufficient to produce near-sightedness, the 
fault would be far more common than it is. The nor- 
mal eye, it is safe to say, is seldom harmed by, is rarely 
incapable of doing without injury, the work of this 
character which is demanded of it. The eyes that really 
suffer — unless indeed the work required of them is 
beyond reason, and is rendered exceptionally trying by 
the unfavorable conditions as to light, position, un- 
hygienic surroundings, etc., under which it must be per- 
formed — are the ones that start with some inherent de- 



406 PREVALENT DISEASES OF THE EYE. 

feet; the ones that are astigmatic or anisometropia or 
in which there is a faulty muscle-balance, or, finally, in 
which there exists an inherited predisposition to myopia. 
Unquestionably, myopia is much less apt to develop in 
such eyes if they are called upon to do but little near 
work, and to this extent the use of the eyes in near vision 
deserves to be regarded as a factor in the causation of 
near-sightedness, but not as a factor of prime im- 
portance. 

The causative relation between the astigmatism or 
the muscle fault and the myopia is easily traced. The 
strain induced by these anomalies leads to congestion of 
the inner tunics of the eye and in time to a low grade of 
choroido-retinitis, and this, in turn, to a disturbance in 
the nutrition of the sclera and to the development of 
posterior staphyloma. In no other country are the re- 
fractive and muscular faults of the eves so diligently 
searched for, and so carefully corrected, as in the United 
States, and the outcome of this, as Dr. Risley, of Phila- 
delphia, has pointed out, is that myopia of high grade is 
by no means as common among us at the present day as 
it was thirty or forty years ago. On the other hand, its 
prevalence has rather increased than diminished during 
this period in Germany, where there is a disposition to 
deride, and to regard as "finicky," the tendency of the 
Amencan ophthalmologists to prescribe glasses for the 
lower grades of these defects. 

It is not improbable that, as a result of inheritance, 
there exists among the Germans an exceptional pre- 
disposition to myopia, which doubtless, in no small 
measure, explains the wide prevalence of this fault 
among them; but I venture the prediction that they will 
meet with but little success in overcoming this predis- 
position until they have learned to emulate, rather than 



ANOMALIES OF REFRACTION. 407 

deride, the example which has been set them by the 
ophthalmologists on this side of the water. 

It is during the early years of life, especially before the 
age of twenty-live, that the disposition of myopia to in- 
crease is chiefly observed. After that age, if the defect 
is not excessive, it is apt to become stationary. It is of 
the greatest importance, therefore, that during these 
early years every effort should be made to overcome this 
tendency to progression; for while a moderate degree of 
myopia is only an inconvenience, a high degree is a mat- 
ter of serious moment, which may even eventuate in loss 
of sight. Choroido-retinitis, involving especially the 
macular region, is a common accompaniment of high 
myopia, and among the complications to be feared are 
intraocular hemorrhage, detachment of the retina, and 
the development of cataract. Very near-sighted eyes 
also are prone to suffer serious consequences from 
slight injuries, which would do no harm to the normal 
organ. 

The myope has to contend with another difficulty 
comparable to, but exactly the opposite of, that which 
besets the hypermetrope. The latter, as has been ex- 
plained, with his fault uncorrected, must always put 
forth an effort of accommodation in excess of that of 
convergence. The myope, on the other hand, with his 
fault uncorrected, must converge more strongly than he 
accommodates — must call upon the internal recti muscles 
to work in excess of the ciliary muscles. Indeed, if his 
near-sightedness is of considerable degree, because of 
the proximity of his far point, he must converge more 
strongly even than the emmetrope, and at the same time 
must do his best to suppress entirely all accommodative 
effort. To the myope this derangement of the normal 
relation between accommodation and convergence is as 



408 PREVALENT DISEASES OF THE EYE. 

trying as the derangement of an opposite character is to 
the hypermetrope, and when it becomes intolerable he, 
too, abandons the effort to maintain binocular fixation, 
and seeks to restore the parallelism between these two 
functions by permitting one eye to squint outward, just 
as the hypermetrope accomplishes the same result by 
allowing one eye to squint inward. If he does not find 
relief in this manner he is apt to suffer, in much the 
same way that the hypermetrope does, with asthenopia, 
headaches, etc., while, of greater moment still, the 
growth of the myopia is promoted by the continual 
strain. 

While this disturbance of the normal relation be- 
tween accommodation and convergence is doubtless the 
chief cause of the occurrence of divergent squint in high 
myopia, there are other factors that favor its develop- 
ment, especially the considerably greater length of the 
eyeball, which, for mechanical reasons, renders the 
converging of the eyes in near vision more difficult. It 
is also one of the chief causes of the asthenopia fre- 
quently observed in myopia of moderate degree, and it 
is in considerable measure through its elimination that 
the growth of near-sightedness is so favorably influenced 
by properly adjusted glasses. To rid themselves of the 
discomfort to which it gives rise, many myopes, whose 
fault has not been corrected by glasses, acquire the 
habit of reading with one eye, closing the other or cover- 
ing it with the hand. 

In some instances myopia is a result of acute systemic 
disease, especially of the exanthematous fevers. A 
softening of the sclera, a diminution of its resisting 
power, occurs, and this leads to the development of 
posterior staphyloma. Without having sufficient war- 
rant for the belief, it has seemed to me probable that 



ANOMALIES OF REFRACTION. 409 

the extreme degrees of myopia not infrequently encoun- 
tered among the negroes in the South commonly origi- 
nate in this way. 

The most characteristic symptom of myopia is in- 
distinctness of distant vision. There is a prevalent be- 
lief that the existence of myopia incapacitates one from 
reading at the usual distance; but this, of course, is erro- 
neous, since it is only of the higher grades of the defect 
that it is true. Besides poor distant vision, the myope 
is apt to complain of muscae volitantes and, as has been 
said, of asthenopia. To enable him to see distant ob- 
jects better, he frequently acquires the habit of keeping 
the eyes half closed, of nipping the lids, and it is from 
this habit that the name "myopia" is derived. How- 
ever, none of these symptoms is pathognomonic, for they 
all are met with in other refractive errors, notably in 
astigmatism of marked degree. 

The ophthalmoscope affords a certain and the read- 
iest means of making a positive diagnosis. It enables 
one also to determine with approximate accuracy the 
amount of the defect, and, besides, throws much light 
upon the probable prognosis; for, even when the myopia 
is of considerable degree, if there are no gross patholog- 
ical changes in the fundus of the eye, the outlook for the 
future is not unpromising. Other things being equal, it 
may be said that the earlier in life myopia develops, 
and the higher the grade already reached in childhood, 
the more unfavorable is the prognosis, and for the 
reason already referred to — that it is in adolescence that 
the defect is chiefly progressive. 

Treatment. — If special training, experience, and pains- 
taking effort are required for the proper treatment of 
hypermetropia, they are the more urgently demanded in 
the treatment of myopia; for the defect is not only, in 



410 PREVALENT DISEASES OF THE EYE. 

itself, more difficult to measure and correct, and as often 
complicated by the presence of astigmatism and faulty 
muscle-balance, but its existence implies an unsound 
condition of the eye, so that not only the comfort of the 
individual, but, in many instances, the preservation of 
sight is at stake. The question whether the defect shall 
increase to the danger-point, or shall be arrested before 
the deeper structures of the eye have suffered irreparable 
damage, hinges, in large measure, upon the skill exer- 
cised in its correction by glasses (Fig. 151). 

If the astigmatism so often found in association 
with myopia is ignored or inaccurately corrected, 




Fig. 151. — Manner in which a concave lens causes parallel rays to diverge 
as from the far point of a myopic eye (de Schweinitz). 



or if the muscle-balance in far and in near vision 
and the accommodative power of the eyes are not taken 
into account, the glasses prescribed are more apt 
to be productive of harm than of good. On the 
other hand, if in their selection regard is had for each 
of these points they can hardly fail to exert a dis- 
tinctly beneficial influence. It is not too much to ex- 
pect that they will relieve the asthenopic symptoms, and 
enable the eyes to be used in near vision, at least in mod- 
eration, without the risk of increasing the myopia. It is 
true that, exceptionally, there are instances — as when 
near-sightedness of high grade is already present in 



ANOMALIES OF REFRACTION. 4II 

childhood — in which, even with the help of glasses, 
the near use of the eyes is not to be permitted; but such 
cases are comparatively rare, and, as a rule, if the glasses 
afford the help which they should, we shall run but little 
risk in permitting the eyes to be used in near work, pro- 
vided we see to it that they are not taxed immoderately, 
that the printed page or other object to be regarded is 
well lighted and kept at the proper distance, and that a 
stooping posture of the head is avoided. 

There is a wide-spread belief that in myopia glasses 
are needed for distant vision only, and that because fine 
print can be read without their assistance thev may be 
dispensed with in near vision. Seldom is this belief 
well founded. Indeed, very generally it is far more 
important for the welfare of the eyes that they should 
be worn in near, than that they should be used in dis- 
tant, vision. In distant vision they are a convenience; 
in near vision they are a therapeutic agent of great value. 
If the myopia is of moderate degree, is equal in the two 
eyes, is uncomplicated by astigmatism, and if, in addi- 
tion, as seldom happens, the muscle-balance at the read- 
ing distance is what it should be, glasses for near vision 
may be dispensed with; but, as a matter of fact, such 
conditions seldom obtain. It is often a difficult matter 
to persuade the myope to wear reading glasses, and a 
contention is apt to arise when this point is broached; 
but in the end he seldom fails to realize the help which 
they afford. Exceptionally, the contention takes a dif- 
ferent form — a willingness is shown to wear near glasses, 
while objection is made to their use in distant vision. 
It is not always so necessary to combat this view, and 
the point may be yielded, provided the eyes are free 
from muscular fault and are not decidedly astigmatic. 

Whether the same glasses may be worn in both far 



412 PREVALENT DISEASES OF THE EYE. 

and near vision will depend upon the degree of the my- 
opia, upon the age and accommodative power of the 
individual, and upon the relative strength of the external 
and internal recti muscles. In youth, if the myopia 
does not exceed two or three diopters, and there is nor- 
mal power of accommodation, it is usually good practice 
to prescribe glasses which give satisfactory distant 
vision, and permit these to be worn for all purposes. 
Later in life, when the eyes have lost part of their accom- 
modative power, this is impracticable, and weaker 
glasses must be provided for near vision. Again, in 
myopia of high grade it is usually best not to correct the 
entire fault, and, under such circumstances, the same 
glasses may often be worn in both far and near vision. 

Whenever a considerable amount of myopia is present 
in childhood the eyes should be examined from time to 
time, in order to learn whether the fault is increasing, 
and if this is found to be the case greater moderation in 
the use of the eyes in near vision should be insisted upon. 

Apart from the systematic wearing of carefully 
adjusted glasses, and the exercise of such precautions as 
have been set forth in the near use of the eyes, the 
progress of myopia is favorably influenced by meas- 
ures which improve the general health. In youth, espe- 
cially, reading for pleasure should be discountenanced, 
and participation in outdoor occupations and amuse- 
ments should be encouraged. Rough sports, however, 
such as football, boxing, and the like, should be avoided. 
The digestive apparatus should be kept in good con- 
dition, and constipation of the bowels should be 
avoided. When the eyes are irritable and the near- 
sightedness inclined to increase, I have found decided 
benefit result from the long-continued use of the opium 
and boracic acid lotion (ext. opii, gr. x; acid, boracic, 



ANOMALIES OF REFRACTION. 4I3 

gr. xl; aq. destil., o ly ) which I have had occasion to 
commend so often. It should be used systematically 
during the sleeping hours, not too heavy pads of gauze 
or soft linen, wet with the lotion, being laid over the 
eyes, and kept in place by a light bandage. 

Operative procedures are seldom called for, though, 
exceptionally, when there is pronounced insufficiency 
of the internal recti muscles a guarded tenotomy 
of one or both of the opponent muscles may be indi- 
cated. Removal of the crystalline lens for the correc- 
tion of myopia of very high grade, a practice which of 
late years has come into vogue, is a procedure of doubt- 
ful advantage, and one attended by considerable risk, 
and the cases in which it is justified are, in my judg- 
ment, extremely rare. 

Astigmatism. — Next to hypermetropia astigma- 
tism is the commonest of the refractive anomalies. An 
astigmatic eye, as the name indicates (darir/ta, "with- 
out a point"), is one that is incapable of bringing the 
rays of light which enter it to a focal point. There are 
two types of astigmatism — regular astigmatism, usually 
of congenital origin, and irregular astigmatism, which is 
frequently an acquired fault. Irregular astigmatism has 
been described already in treating of " Opacities of the 
Cornea " and does not call for further consideration. 

Regular astigmatism, often transmitted from one gen- 
eration to another, is commonly due to asymmetry in 
the curvature of the cornea, to the different meridians 
of the cornea varying in their convexity; less frequently, 
to asymmetry in the curvature of the crystalline lens, 
or to the lens occupying an oblique position with refer- 
ence to the visual axis. The result of each of these 
faults is that the rays of light passing through the differ- 
ent meridians of the dioptric media of the eye are un- 



4H PREVALENT DISEASES OF THE EYE. 

equally refracted, those which pass through the most 
convex meridian, or through the meridian to which the 
obliquity of the lens corresponds, being most quickly 
focused, those through the less convex meridians less 
quickly, and those through the least convex meridian, 
or through the meridian corresponding to the axis about 
which the lens is rotated, least quickly. The outcome 
of this is an imperfect, a blurred, retinal image, which 
is very annoying, and which the eye, at the expense of 
much effort, endeavors to make more distinct. The 
amount of blurring depends upon the measure of success 
which attends this effort, as well as upon the degree of 
the astigmatism. 

In some eyes a large part of the static astig- 
matism is corrected, is rendered "latent," through 
the action of the ciliary muscle, which, contracting 
asymmetrically, produces a compensatory lenticular 
astigmatism or, perhaps, a tilt of the lens, which serves 
the same purpose. It is the ever-present strain involved 
in this effort that is the chief cause of the asthenopia, 
the headaches, etc., so commonly associated with astig- 
matism. A fact confirmatory of this is that when the 
astigmatism is of very high grade there is usually little 
complaint of asthenopia, only of imperfect vision, be- 
cause, under such circumstances, the eye soon learns 
that by no effort which it is capable of making can clear 
vision be secured, and so abandons the task and accepts 
the inevitable. 

Many astigmatic persons also learn to improve their 
vision, as myopes do, by nipping the lids, whereby they 
not only secure the advantage of a narrow, slit-shaped 
pupil, but, through the pressure exerted by the lids, 
actually alter to their advantage the curvature of the 
cornea. In order to obtain a larger retinal image they 



ANOMALIES OF REFRACTION. 415 

also frequently hold the printed page abnormally close 
to the eyes. For these reasons, and because their dis- 
tant vision is manifestly indistinct, they are often sup- 
posed to be myopic. Unlike that of the myope, how- 
ever, their vision, if the defect is considerable in degree, 
is imperfect at all distances. They are more sure, too, 
to be asthenopic, and, as has been pointed out, they are 
liable to many grave lesions of the eve in consequence 
of the ever-present strain to which their accommodative 
apparatus is subjected. 

The simplest form of astigmatism is that in which the 
eve is emmetropic in one meridian and hyperme- 
tropic or myopic in the opposite meridian. This 
tvpe of the defect, simple astigmatism, as it is called, 
is, however, the exception, and it is usually with com- 
pound astigmatism that we have to deal, that is, with 
astigmatism in which there is hypermetropia or myopia, 
as the case may be, in one meridian and a greater 
amount of the same defect in the opposite meridian. 
More rarely mixed astigmatism is encountered — there 
is hypermetropia in one meridian and in the opposite 
meridian myopia. 

In corneal astigmatism the meridian of shortest focus 
is apt to be approximately vertical, the meridian of 
longest focus approximately horizontal. In lenticular 
astigmatism, on the other hand, it is usual to find the con- 
ditions reversed. The first type, being the more com- 
mon, is known as astigmatism with, or according to, the 
rule; the last, as astigmatism against the rule. A low 
grade of astigmatism "with the rule," a quarter of a 
diopter, for example, usually gives rise to little or no 
inconvenience, indeed, is so common as hardly to be re- 
garded as an abnormality. On the contrary, astigma- 
tism " against the rule," generally located, as has been 



416 PREVALENT DISEASES OF THE EYE. 

said, in the lens, deserves to be regarded as a wider de- 
parture from the normal, and, though it be ever so 
slight in degree, is apt to cause trouble. Even the 
lowest grades of astigmatism against the rule, therefore, 
should be corrected — the more so because the discrep- 
ancy between the manifest and the total defect is apt to 
be greater than is the case in astigmatism with the rule. 

The fact, of frequent observation, that astigmatic 
glasses after having been worn for some months have to 
be increased in strength, finds its explanation in this 
latency of a part of the error. Latent hypermetropia 
usually can be made evident by a few instillations of a 
cycloplegic; but this is not true of latent astigmatism. 
Only as a result of the correction of the manifest defect 
does the induced, the compensatory, lenticular astig- 
matism slowly disappear, and the static error become 
fully manifest. Thus it happens that an eye which is 
made comfortable for half a year or more by a cylindrical 
glass of a certain strength may eventually call for one 
twice as strong. In exceptional instances, especially 
in progressive myopia, there may be an actual increase of 
astigmatism; but commonly it remains unchanged, 
and there is only an apparent increase due to the defect 
becoming more and more manifest. 

There is a popular impression that an astigmatic 
glass once right is always right; but, like many 
such impressions, this one is without warrant. 
Indeed, not only may an increase in the strength 
of the glass be called for, but also a change in 
its position; for the astigmatism may undergo what is 
known as orientation — a change may occur in the direc- 
tion of the principal meridians,* doubtless another re- 

* The meridians of greatest and of least convexity are called the 
"principal meridians," and are at right angles to each other. 



ANOMALIES OF REFRACTION. 4I7 

suit of the effort which the eve puts forth to correct its 

own defect. 

Although regular astigmatism is usually a congenital 
fault and frequently, as has been said, an inherited one, 
it may also be acquired. Acquired astigmatism is often 
of traumatic origin. Any wound of the eye which pro- 
duces a permanent change in the curvature of the cornea 
may give rise to it. A familiar example of this is the 
astigmatism against the rule which very generally fol- 
lows the operation of cataract extraction. Severe in- 
flammation of the cornea may also produce it, more 
especially a perforating corneal ulcer. It is more incon- 
stant than congenital astigmatism, being liable to vary 
in degree as the asymmetry of the cornea increases or 
diminishes, and because of this tendency a readjustment 
of the glasses prescribed for its correction is more often 
necessary. 

Because the common belief is to the contrary, it is well 
to emphasize the fact that the existence of a degree of 
astigmatism capable of giving rise to pronounced 
asthenopic symptoms is not incompatible with normal 
acuteness of vision. Especially is this true, in my ex- 
perience, of astigmatism against the rule, of which the 
eve seems more intolerant, and with which, so far as 
sharpness of vision is concerned, it seems to cope more 
successfully. Often have I met with cases of this de- 
fect in which, without glasses, vision was fully up to the 
normal standard, and yet in which the prescribing of 
weak cylinders has afforded immediate relief from head- 
aches, asthenopia, etc. 

The detection of the lower grades of astigmatism is a 

matter which often taxes the skill of the specialist; but 

when the error is marked in degree it is not difficult to 

prove its existence. The easiest way to do this is by 

27 



418 PREVALENT DISEASES OF THE EYE. 

means of a stenopaic disc, or, if this is not available, by 
means of an improvised stenopaic apparatus which any 
one can make by cutting a narrow slit in a visiting-card. 
When such a contrivance is held in front of, and close to 3 
an eye the vision of which is defective from any refrac- 
tive error, an appreciable improvement in vision, espe- 
cially in distant vision, will result. If the defective 
vision is due to a symmetrical error, for example, to my- 
opia, the improvement will be the same in whatever 
direction the slit is turned. If, however, it is due to 
astigmatism, vision will be much sharper when the slit 
is held in a certain easily found position, and much less 
sharp when it is held in the opposite direction. The 
test is a rough one; but, if the difference in vision is 
considerable in the two positions, it is conclusive, and 
warrants a positive diagnosis of astigmatism. It also 
indicates the direction of the principal meridians, since 
the greatest improvement in sight is obtained when the 
slit is held at a right angle to the faulty meridian, or, if 
both are at fault, to the one which is most so. How- 
ever, as this test is conclusive only when the astigmatism 
is considerable in degree, it should be borne in mind 
that a negative result does not exclude the possible ex- 
istence of a significant amount of the defect. 

Since astigmatism is so prevalent an error, and is so 
often a chief factor in the causation not only of a host 
of ocular maladies but of many obscure disturbances 
of the nervous system, such as headache, neurasthenia, 
nausea, nervous dyspepsia, vertigo, insomnia, somno- 
lency, incapacity for mental concentration, chorea, etc., 
its significance, its etiologic importance, can not be too 
strongly impressed upon the general practitioner. 
"Remember the eyes" is a dictum which, if taken to 
heart, will often stand him in good stead, and enable 



ANOMALIES OF REFRACTION. 4IO, 

him to solve many a diagnostic riddle which otherwise 
might prove insolvable. 

Treatment. — There is but one way to treat astigma- 
tism, and that is, with painstaking care, to correct it by 
means of glasses; for, being simply a defect in the con- 
formation of the eye and not a pathological condition, 
there are no means by which it can be eliminated or even 
lessened in amount. Theoretically, the glasses pre- 
scribed for its correction should be worn constantly; 
but, practically, this is not always necessary, for when 
the defect is of low grade, and is approximately with 
the rule, complete relief is not infrequently obtained 
by their systematic use in near vision only. In astig- 
matism against the rule, even if the error be slight in 
degree, it seldom happens that relief is secured unless 
the glasses are worn constantly. This is usually the 
case also when there is a considerable difference in the 
amount of the astigmatism in the two eyes, or when it is 
with the rule in one eye and against the rule in the other. 
As oftener than not other refractive faults are found 
associated with astigmatism, the question whether the 
glasses shall be worn only in near vision or constantly 
may depend upon the nature of the associated error. 

It is by means of cylindrical lenses that we are enabled 
to correct astigmatism. If the astigmatism is "simple" a 
piano-cylindrical lens suffices for its correction — a plano- 
concave cylinder (Fig. 152) if the astigmatism is myopic, 
a plano-convex cylinder (Fig. 153) if it is hypermetropic. 
If the astigmatism is "compound" or "mixed," a 
sphero-cylindrical lens is usually necessary , that is, a lens 
one surface of which is spherical — concave or convex, as 
the case may be — and the other cylindrical. In the direc- 
tion of its axis a piano-cylinder has only the refractive 
value of a plate of glass with parallel surfaces, while in 



420 PREVALENT DISEASES OF THE EYE. 

the direction perpendicular to its axis its refractive power 
is greatest. Hence the effect of a cylindrical lens upon 
vision depends upon the position in which the axis is 
placed. It is necessary, therefore, in prescribing glasses 
for the correction of astigmatism to determine with ac- 
curacy not only the required strength of the cylinder, 
but also the exact position in which it is to be worn. 
The question whether a piano-cylinder or a sphero- 
cvlinder is required has also to be determined, and, if 
the latter is called for, what shall be the strength of the 
spherical surface. And here, again, it is of the utmost 




Fig. 152. — Plano-concave cylinder. 

importance that the muscle-balance of the eyes should 
be taken into account. 

The correction of astigmatism by means of cylindrical 
lenses has a twofold effect — vision is greatly improved, 
in most instances brought up to the normal standard, 
and, even more important than this, the previously ex- 
isting accommodative strain is relieved. The latter 
effect may well be called the more important, since it is 
through this that relief is obtained from the manv ill 
consequences, local and remote, to which uncorrected 
astigmatism usuallv gives rise. 

It is well to bear in mind that the relief which cylin- 
drical lenses afford is not appreciated, in many instances, 
until they have been worn for a time — long enough for 



ANOMALIES OF REFRACTION. 42I 

the eyes to learn to adjust themselves to the new condi- 
tions, and to accept the help which they give. Indeed, 
when they are first put on a transient aggravation of the 
asthenopic symptoms is experienced not infrequently. 
In children this seldom happens, but in persons more 
advanced in age it is often pronounced. It is well, 
therefore, that the patient should be warned before- 
hand what to expect, otherwise the glasses may be 
petulantly thrown aside under the impression that 
they "do not suit," and much undeserved opprobrium 
heaped upon the one who has prescribed them. 

How long the glasses first given will continue to 
afford the needed relief is a matter of much uncer- 
tainty. Exceptionally, especially in astigmatism against 
the rule, a change may be called for within a few 
months, while in other instances they may be worn 
with comfort for many years. 

In youth, so far, at least, as the astigmatism is con- 
cerned, the same glasses may be worn for all purposes, for 
near as well as for distant vision; but after the presbyopic 
age has been reached a lens especially adapted for near 
vision becomes necessary — one that, in addition to cor- 
recting the astigmatism, will afford the needed mag- 
nifying power. As a rule, this can be done most con- 
veniently by means of a bifocal lens, by adding to the 
distance glass a "lenticular" of the required strength. 

There are several methods by which the existence of 
astigmatism can be ascertained and its direction and 
degree determined. The ophthalmoscope affords the 
readiest means of doing this, and this method has the 
great advantage that it does not necessitate the use of 
a cycloplegic; but even in the hands of the most expert 
the information which it gives is only approximately 
exact, and must be confirmed by other means. The 



422 PREVALENT DISEASES OF THE EYE. 

ophthalmometer, which some hold in high esteem, is 
not to be relied upon, since it gives only the astigmatism 
of the anterior surface of the cornea, and tells us noth- 
ing of asymmetry either of the posterior corneal sur- 
face or of the lens. Skiascopy, the shadow test, or, as 
it is sometimes called, retinoscopy, affords much more 
exact results, and is the most trustworthy of the ob- 
jective methods of measuring astigmatism as well as 
other refractive errors, but its employment necessitates 
the use of a cycloplegic. 

Of all the methods of measuring astigmatism the 
most reliable— the court of last resort, as it has been 
called — is the subjective method, the test with glasses, 
test-types, and the astigmatic dial. Even here contra- 
dictory results and inconsistencies are not uncommon, 
and it often happens that in endeavoring to reach a 
definite conclusion the skill and patience of the most 
experienced are sorely tried. The beginner usually 
derives much help from the use of a cycloplegic, and 
in the opinion of many this is essential to the attainment 
of accurate results. With this view, however, I am 
not in accord; for my experience is that, in many in- 
stances, the dilatation of the pupil attendant upon the em- 
ployment of a cycloplegic introduces as many x quan- 
tities as are eliminated through the suppression of the 
power of accommodation. The advantage gained from 
the paralysis of the ciliary muscle is unquestionably 
great; but this is nearly, if not quite, offset by the dis- 
advantage of having to make the visual tests with a 
widely dilated pupil. The problem would be different 
did we possess a cycloplegic which was not a mydriatic 
— a pupil dilator — as well, or had Nature been less 
niggardly, and made the whole of the cornea and the 
whole of the crystalline lens as optically perfect as she 



ANOMALIES OF REFRACTION. 423 

has the visual zone of each ; but such a cycloplegic has yet 
to be found, and, as the ophthalmoscope and skiascopy 
have shown us, Nature, as yet, has busied herself but 
little in perfecting those outlying portions of the cornea 
and lens which, under usual conditions, take no part in 
the formation of retinal images.* To show how great 
may be the lack of agreement between the results of 
tests made with and without a cycloplegic, I may men- 
tion that in a few instances I have found the total hyper- 
metropia to be less than the manifest, and in a few 
others have seen the direction of an astigmatism 
exactly reversed through the induction of mvdriasis. 
Still, I would not be understood as being opposed in 
general to the use of a cvcloplegic as an aid in the de- 
termination of refractive errors; for I recognize the fact 
that, in not a few instances, a dilated pupil is a lesser 
evil than an irritable ciliarv muscle, which is changing 
its tension from moment to moment. 

There is a popular impression that after glasses pre- 
scribed for the correction of astigmatism have been 
worn for a time, and have given the needed relief, they 
may be put aside without detriment. It is hardly neces- 
sary to say that this is rarely the case. In low grades 
of astigmatism with the rule, especially if the work re- 
quired of the eves becomes less exacting, this some- 
times happens; but, as a general truth, it may be said 
that cylindrical glasses once needed are always needed. 
"Until you get to heaven," is the way I sometimes 
put it in answer to the frequently propounded ques- 

* It is interesting to note that this is especially true of the eye of 
the negro. I am not aware that attention has been called to this 
fact ; but from my own observation I have no hesitation in stating 
it as a fact. Especially does one find frequently in the eye of the 
negro marked examples of "symmetrical aberration," as defined by 
Jackson. 



424 PREVALENT DISEASES OF THE EYE. 

tion, "How long shall I have to wear these horrid 
glasses ?" 

Anisometropia is the rather awkward term em- 
ployed to designate a difference between the refractive 
state of the two eyes. When of moderate degree this 
condition often gives rise to asthenopia, because of the 
unequal accommodative effort which it necessitates; 
when pronounced, it tends to promote the development 
of strabismus. Exceptionally, it proves a blessing in 
disguise, one eye being used with satisfaction in distant 
vision, the other with equal satisfaction in near vision. 
This is the case especially when one eye happens to be 
moderately myopic, the other nearly emmetropic; for 
under such circumstances the emmetropic eve does good 
service in distant vision, while the myopia of the other eye 
serves the purpose of a convex lens, and obviates the 
necessity of presbyopic glasses. As a change in the re- 
fraction of either eye is liable to occur, the difference 
between the two may vary, the anisometropia be- 
coming, in the course of time,, greater or less, as the case 
may be. 

Treatment. — As a rule, it is practicable and best to 
equalize the focus of the eyes by giving to each the lens 
which its refractive fault calls for. In most instances, 
by making the sight and the accommodative effort of 
the two equal, this results in the establishment of com- 
fortable binocular vision. However, it is not always 
feasible to do this. In the first place, the difference 
between the required glasses may be so great as to ren- 
der impracticable fusion of the retinal images, which 
under such circumstances would differ considerably 
in size. In the next place, when the eyes have been 
long divorced, so to speak, pronounced muscular faults 
are apt to develop. These give rise to no inconvenience 



ANOMALIES OF ACCOMMODATION. 425 

as long as the eyes make no effort to work together, 
but are liable to cause much annoyance when, through 
the action of glasses, binocular vision is reestablished. 
Such muscular faults frequently disappear as a result 
of the new relations established between the eyes; but 
this is not always the case. 

The difference in strength which it is practicable to 
make between the glasses prescribed for the correction 
of anisometropia varies considerably in different in- 
dividuals. In some instances a difference of 4 or 5 
diopters proves acceptable, while in others a difference 
appreciably less than this may give rise to annoyance. 
In the very high grade of anisometropia which exists 
when one eye has been operated upon for caratact, and 
the other eve still retains good sight, it is seldom possible, 
by any arrangement of glasses, to secure comfortable 
binocular vision. Under such circumstances it is best, 
therefore, to give a glass to the sharper-seeing eye only. 
If this happens to be the one that has been operated 
upon for cataract, it may be necessary, in order to es- 
tablish the habit of using this eye, to "exclude" the 
other eye for a time by placing an opaque disc or a 
ground glass before it. 

ANOMALIES OF ACCOMMODATION. 
A sharp distinction is to be drawn between the anom- 
alies of accommodation and the anomalies of refraction. 
The latter, as has been explained, are the expression 
of certain faults in the conformation of the eye; the 
former have to do with the capacity of the eye to alter 
its focus, to adjust itself to the sharp-seeing of objects 
at varying distances. To a comprehension of the anom- 
alies of accommodation a clear conception of the normal 
accommodation of the eye is essential. 



426 PREVALENT DISEASES OF THE EYE. 

According to the commonly accepted theory of the 
accommodation of the eye, propounded by Helmholtz, 
the crystalline lens, when unrestrained, has an inherent 
tendency to become more convex. When the eye is 
fixed upon distant objects this tendency is held in check 
through the traction exerted upon the lens capsule by 
the zonule of Zinn. The tension of the zonule is con- 
trolled by the action of the ciliary muscle. When this 
muscle is at rest the tension of the zonule is at the max- 




Fig. 154. — Changes in the conformation of the lens during accommodation. 
The solid white outline of the lens, /, shows its form when the zonule, or 
suspensory ligament, is tense. The dotted line shows the increased curva- 
ture of the anterior surface during accommodation, and its advancement into 
the anterior chamber, a. 2 is the suspensory ligament; m, the ciliary muscle; 
and i, the iris (Landolt). 

imum; when it contracts the tension is lessened. The 
adjustment of the eye for the sharp-seeing of near ob- 
jects is brought about, then, by the contraction of the 
ciliary muscle, which relaxes the zonule and permits 
the lens to become more convex (Fig. 154). The exact 
degree of relaxation of the zonule necessarv to produce 
the required change in the focus of the eve is learned 
through experience, and varies in different individuals, 
being markedly influenced by age. 



ANOMALIES OF ACCOMMODATION. 427 

From this description it is evident that the ability of 
the eve to accommodate itself for different distances 
may be impaired in any one of several ways: The lens 
may lose, to a greater or less degree, its elasticity, its 
tendencv upon relaxation of the zonule to become more 
convex. It may, as a congenital fault, possess this ten- 
dency to a subnormal degree. The ciliary muscle may 
lose its power, may become paralyzed, or it may become 
spasmodically contracted, or it may be, congenitally, 
weak and inefficient. All of these conditions are en- 
countered, and each of them produces a definite dis- 
turbance in the accommodative power of the eye. 

The first-mentioned condition — the loss of elasticity 
of the lens — occurs in every eye as a result of advancing 
age, and, when it has reached a certain degree, con- 
stitutes the fault known as presbyopia or, popularly, as 
old-sightedness. The second and last conditions — con- 
genital inelasticity of the lens, and congenital inef- 
ficiency of the ciliary muscle — are of not infrequent oc- 
currence, and, existing separately or conjointly, give 
rise to the anomaly which I have called "subnormal 
accommodative power/' The third condition — par- 
alysis of the ciliary muscle — may occur suddenly at any 
time of life, and is oftenest due to syphilis or to diph- 
theria. The fourth condition — spasm of the ciliary 
muscle — is met with occasionally as a complication in 
astigmatism and other refractive errors, but is of less 
frequent occurrence than some authorities would have 
us believe. 

Presbyopia (Old-sightedness). — As a result of its 
growth and the. sclerosis of its older central fibers, 
which in time come to form the hard nucleus character- 
istic of the senile lens (see Chap. IX), the crystalline lens 
gradually loses its elasticity, its capacity to become 



428 PREVALENT DISEASES OF THE EYE. 

more convex upon relaxation of the zonule. This dimi- 
nution of elasticity begins to manifest itself, as has been 
mentioned already, very early in life, even in childhood; 
but usually does not become sufficiently marked to 
cause inconvenience until about the forty-fifth year, 
when it interferes with the sharp-seeing of near objects, 
as in reading, sewing, and the like. Its gradual devel- 
opment also lessens the ability of the eye to cope with 
refractive faults, and so, if these are present, may lead, 
as, for example, in hypermetropia, to indistinctness of 
distant as well as of near vision. 

With the advent of presbyopia the complaint is 
often heard that the light, especially the light which one 
has been in the habit of reading or sewing by at night, is 
not as good as it formerly was, or that the newspaper 
is not as well printed as it used to be. The thread- 
ing of a needle becomes a difficult task, and the 
printed page or the sewing is held inconveniently far 
away from the eyes. If these hints are acted upon, 
and the needed glasses procured, satisfactory and 
comfortable near vision is obtained at once; but if the 
individual, as often happens, continues to struggle 
along without their help, hoping to avoid, or at least 
postpone, this confession of advancing years, the strain 
upon the eyes soon begins to tell, and asthenopic symp- 
toms, or headaches, perhaps, manifest themselves. 

In rare instances the emmetropic eye retains its ability 
to see near objects distinctly considerably beyond the 
usual presbyopic age; but, nearly always, when this 
ability is present after the forty-seventh or forty-eighth 
year, it will be found that one or both eyes are myopic, 
and only exceptionally are such persons not helped by 
properly adjusted glasses, for onlv exceptionally does 
it happen that the myopia is just of the requisite degree 



ANOMALIES OF ACCOMMODATION. 429 

to neutralize the presbyopia. The failure oi near vision 
before the forty-fifth year commonly indicates the exist- 
ence of hypermetropia or, perhaps, of hypermetropic 
astigmatism. 

Treatment. — There is but one way to deal with pres- 
byopia, and that is bv giving the needed glasses. There 
is no warrant for the claim, put forth by unprincipled 
quacks, that it can be "cured," or even that its develop- 
ment can be postponed, by such procedures as massage, 
the use of " eve-cups, " and the like. 

There is a common belief that in the selection of 
glasses for " old-sight " the services of the oculist may be 
dispensed with; that they, at all events, can be " fitted" 
bv anv one who "carries a stock" of spectacles, or can 
be chosen with safety by the individual himself. The 
fallaciousness of this view can not be too emphatically 
insisted upon. In prescribing glasses for presbyopia 
one often has to take into account unsuspected refractive 
faults, such as astigmatism or anisometropia. The 
muscle-balance also has to be considered, and the in- 
fluence which the glasses that seem to be indicated exert 
upon it. The neglect of these points, which fall defi- 
nitely within the province of the medical specialist, 
gives rise to much unnecessary discomfort, and not in- 
frequently to the more serious consequences apt to fol- 
low long-continued eve-strain. 

It should be borne in mind that presbyopia is a pro- 
gressive condition, and that the glasses prescribed for 
its correction must be increased in strength from time 
to time. Usually, if they have been accurately adjusted, 
thev afford the needed help for about two years; but 
there are many exceptions to this rule, in some instances 
a change being called for sooner than this, and in others 
not so soon. After the seventieth year it is not often 



43° 



PREVALENT DISEASES OF THE EYE. 



necessary to increase further the strength of the glasses, 
for by this time the eye has lost entirely its power of 
accommodation. In exceptional instances, with the 
acquisition of so-called " second sight/' which, as has 
been explained, is usually a premonitory symptom of 
developing cataract, the glasses previously worn have to 
be considerably weakened, or may even be put aside 
altogether. 

In presbyopia, if glasses are required for distant vision 
as well as for near, it is commonly best to prescribe 



v 




Fig. 155. — Cemented bifocal lens. 
B, Correction for distant vision; A, 
"lenticular," added for near vision. 



Fig. 156. — "Invisible" bi- 
focal lens. The "lenticular," 
which is countersunk, is made 
of glass having a very high in- 
dex of refraction. 



bifocal lenses (Figs. 155 and 156), as this does away 
with the necessity for two pairs of glasses and the in- 
convenience of having to change frequently from one to 
the other. At first such lenses often prove annoying; 
but in a short time the eyes become accustomed to them, 
and they afford much comfort. 

Paralysis of the Ciliary Muscle.— The most com- 
mon causes of this anomaly, as has been stated, are 
diphtheria and syphilis. Other conditions which may 
give rise to it are affections of the central nervous 
system — tabes dorsalis, especially — influenza, diabetes, 



ANOMALIES OF ACCOMMODATION. 43 1 

ptomaine poisoning, and contusion of the eyeball. It is 
a prominent symptom, too, in poisoning by belladonna 
(I have observed it in one instance in a susceptible in- 
dividual from the application of a belladonna plaster); 
and it is to be remembered that it is sometimes due to 
the accidental and unconscious application of atropin 
to the eve, as in an instance which came under my obser- 
vation recently where a physician rubbed one of his 
eves with his ringer after handling a hypodermic tablet 
of atropin and morphin. 

Xot infrequently paralysis of the ciliary muscle is 
accompanied by paralysis of the sphincter pupillae and 
consequent mydriasis. This is more apt to be the case 
when the paralysis is of syphilitic origin or when it oc- 
curs in the course of tabes. It happens less often in 
post-diphtheritic paralysis. In cases due to acquired 
syphilis it is not uncommon to find not only the sphincter 
pupillae implicated, but all the extraocular muscles 
supplied by the third nerve. In post-diphtheritic cvclo- 
plegia both eves are usually involved, while cases 
dependent upon syphilis are commonly unilateral. 

The prominent symptom is impairment of sight, 
which usually manifests itself suddenly. In emme- 
tropic eves only near vision is affected; but both far and 
near vision are impaired in eves that are hypermetropic, 
because such eves require an effort of accommodation 
to see distinctly even distant objects. If the paralysis 
is complete, ability to read ordinary print is lost. The 
diagnosis is established by finding that a convex glass 
often or twelve inches focus enables fine print to be read 
with ease. 

The prognosis, as a rule, is favorable, especially in 
the post-diphtheritic cases, which commonly recover 
within a few weeks. The most unfavorable cases are 



432 PREVALENT DISEASES OF THE EYE. 

those which are dependent upon disease of the central 
nervous system. 

Treatment. — This necessarily depends upon the pri- 
mary cause of the affection. In post-diphtheritic cases 
and in cases following influenza tonics containing iron 
and quinin, and especially strychnin, are indicated. In 
cases of luetic origin potassium iodid, in generous doses, 
and strychnin are the most useful remedies. Local 
remedies are of but little value, though eserin, in weak 
solution, is usually commended. 

Spasm of the Ciliary Muscle (Spasm of Accom- 
modation). — The most typical spasm of the ciliary 
muscle is that which is produced by the action of eserin 
upon the eye. The contraction of the muscle causes a 
marked lessening of the tension of the zonule of Zinn, 
which, in persons w T ho have not yet reached the presby- 
opic age, is attended by an exceptional increase in the 
convexity of the crystalline lens. This results in the 
production of a transient myopia, the degree depending 
upon the age of the individual and the strength of the 
eserin solution employed. 

Exceptionally, something equivalent to this occurs 
in ametropic eyes which, without suitable glasses, have 
been strained by much near work. It is more prone to 
occur in astigmatic eyes, particularly in astigmatism 
against the rule, or when the astigmatism is complicated 
by insufficiency of the internal recti muscles. It is 
usually attended by marked asthenopic symptoms, and 
not infrequently the existence of a low grade of choroido- 
retinitis is revealed by the ophthalmoscope. It neces- 
sarily masks the true refractive condition, causing 
hypermetropic astigmatism and even considerable de- 
grees of hypermetropia to simulate mvopia, and exag- 
gerating any real myopia that may be present. 



ANOMALIES OF ACCOMMODATION. 433 

Treatment. — The muscle-balance in far and near 
vision having been determined, a cycloplegic (atropin or 
hyoscyamin) should be prescribed. In most instances 
this will quickly overcome the ciliary spasm, though 
exceptionally' its use may have to be continued for some 
days before this is accomplished. As soon as this has 
been brought about, a careful measurement of the re- 
fractive condition of the eyes should be made, and 
glasses, usually for constant wear, should be ordered. If 
the choroido-retinitis is marked in degree, a period of 
abstinence from near use of the eyes should be insisted 
upon, and a lotion of opium and boracic acid, to be em- 
ployed until all symptoms of irritation have subsided, 
should be prescribed. 

Subnormal Accommodative Power. — In a paper 
published in the " Transactions of the American Oph- 
thalmological Society/' in 1891, I described a condition 
which I believed to be a not infrequent cause of asthen- 
opia in young persons, and for which I proposed the 
name "Subnormal accommodative power." Although 
the detection and correction of this defect can hardly be 
said to fall within the province of the general practi- 
tioner, I may, perhaps, be excused for going somewhat 
into detail in describing it. 

The characteristic symptoms of this condition, as 
set forth in my paper, are quite different from those of 
presbyopia. There is no complaint of indistinctness 
of near vision, but of asthenopia and not infrequently of 
headache. The underlying cause in most instances 
was assumed to be a congenital insufficiency of the 
ciliary muscle. A congenital rigidity, or lack of elas- 
ticity, of the crystalline lens would account for the 
condition as satisfactorily. The anomaly may exist in- 
dependently of any other fault of the eye, or may compli- 
28 



434 PREVALENT DISEASES OF THE EYE. 

cate other errors, refractive or muscular. The early 
development of presbyopia occasionally observed in 
emmetropic individuals is one of its manifestations. 

Its existence is not to be determined by the tests em- 
ployed in presbyopia, — for the finest print can be read 
with facility and, for a short while, at least, at as near a 
point as the age of the individual would lead one to ex- 
pect, — but is demonstrated by a lack of accordance be- 
tween the lateral muscle-balance in far and in near 
vision, as shown by the vertical diplopia test of von 
Graefe. 

This test, in eyes that are in every way normal, shows 
an orthophoric muscle-balance in distant vision, but 
at the reading distance shows an exophoria of from 3° 
to 5 . Indeed, whatever the muscle-balance in distant 
vision may be, unless certain modifying conditions to 
be described presently exist, the test will show in near 
vision a difference, in the sense of exophoria, of 3 to 5 . 
For example, if an esophoria at 20' of 5 is shown, 
orthophoria or, at most, an esophoria of i° or 2° should 
be found at 13". If, on the other hand, an exophoria of 
5 is shown in distant vision, 8° to io° of exophoria may 
be predicted in near vision. 

A difference between the far and near muscle-bal- 
ance, in the sense of exophoria, appreciably greater 
than 5 indicates that the convergence effort is not sup- 
ported, as it is under normal conditions, by a corre- 
sponding accommodative effort. This is what happens 
in uncorrected myopia, and it explains the excess of exo- 
phoria at the reading distance characteristic of this de- 
fect. On the other hand, a difference appreciably less 
than 3 indicates that an unusual accommodative effort 
is being put forth, an effort in excess of the convergence 
effort which normally should accompany it. 



ANOMALIES OF ACCOMMODATION. 435 

A typical example of this condition is shown when a 
cycloplegic has been used, and the eyes have not fully 
recovered from its influence. If under such circum- 
stances, even when the accommodation has recovered 
sufficiently to enable fine print to be read, a test of the 
near muscle-balance be made by von Graefe's method, 
a result will be obtained very different from that shown 
bv the same test before the cycloplegic was used. In- 
stead of an exophoria of 3 or 4 or 5 , the test will show 
no exophoria at all, or, at all events, several degrees less 
than was found previously. The meaning of this is 
that the still somewhat enfeebled ciliary muscle requires 
excessive stimulation to enable it to perform the work 
required of it, and that, because of the intimate relation 
which exists between the accommodative effort and the 
convergence effort, this is necessarily accompanied by 
a corresponding stimulation of the conjointly acting 
interni. 

No better illustration than this could be offered of 
what occurs in the condition for which I have suggested 
the name subnormal accommodative power. In the 
one case we have a transient enfeeblement of the ciliary 
muscle; in the other, a ciliary muscle congenitally weak, 
or, what amounts to the same thing, an inelastic crys- 
talline lens, to cope with which demands inordinate 
action upon the part of the normal ciliary muscle; but, 
so far as the muscle-balance test in near vision is con- 
cerned, the result is the same in each. 

Asthenopic symptoms, then, manifest themselves in 
subnormal accommodative power, as they usually do 
when the normal parallelism between the two functions 
is disturbed, because the accommodative effort is in 
excess of the convergence effort. 

The rule for the detection of subnormal accommoda- 



436 PREVALENT DISEASES OF THE EYE. 

tive power, deducible from what has gone before, is 
this: Ascertain^ by the vertical diplopia test, the muscle- 
balance in far and in near vision. If the latter does not 
show a difference, in the sense of exophoria, of at least 2°, 
the existence of subnormal accommodative power is in- 
dicated. It is well to make the test both with and with- 
out correction of any refractive fault that may be pres- 
ent; but the result — the difference between the far and 
near muscle-balance — is usually the same under both 
conditions. In applying the test one should be careful 
to exclude the possible influence, such as has been de- 
scribed, of a cycloplegic. As to this, it may be well to 
state, my experience shows that for, at least, eight days 
after the discontinuance of a two-grain solution of 
hyoscyamin hydrobromate the result of the test is 
almost sure to be misleading. 

Treatment. — It is manifest that we have in convex 
glasses the means of getting rid of the unpleasant con- 
sequences of subnormal accommodative power. In 
uncomplicated cases, that is to say, in cases in which no 
refractive or other muscular fault exists, they will be re- 
quired for near vision only. Under such circumstances, 
the strength of the glass needed is easily determined by 
following this simple rule: Ascertain by trial the weakest 
convex spherical glass that will give, at 13", the minimum, 
amount of normal exophoria (2 to 3 ), and prescribe this 
for systematic use in near vision. Should the strength of 
this glass be so considerable as to bring the binocular far 
point inconveniently close to the eyes, reduce it, and add 
esophoric prisms of such strength as will give the re- 
quired exophoria. 

In complicated cases the correction needed for distant 
vision should be determined by the usual tests, and then, 
with this correction, the test for subnormal accommoda- 



ANOMALIES OF ACCOMMODATION. 437 

tive power should be employed in the manner just de- 
scribed, convex glasses or, possibly, sphero-prisms, being 
added until the required exophoria at the reading dis- 
tance is obtained. This, of course, involves the neces- 
sity, in such cases, for two pairs of glasses, one for far, 
the other for near, vision, unless, as a matter of con- 
venience, bifocal lenses are preferred. 

As set forth in a recent paper,* published in the 
"Transactions of the American Ophthalmological So- 
ciety" for 1904, and in the "Johns Hopkins Hospital 
Bulletin" for January, 1905, the results which I have 
obtained in this condition of subnormal accommodative 
power by following the rules just given — prescribing at 
times for young asthenopic emmetropes convex glasses 
of considerable strength for near vision, and for young 
hypermetropes stronger glasses for near than for distant 
vision, and occasionally combining with these esophoric 
prisms — have been so eminently satisfactory, that the 
practice has become as much a matter of course with me 
as the correction of astigmatism or of hypermetropia 
itself. 

* " The Importance of Testing the Ocular Muscle-balance for 
Near, as well as for Distant Vision." 



CHAPTER XII. 
MUSCULAR ANOMALIES OF THE EYES. 

The muscular anomalies of the eyes are divisible into 
two major groups — manifest muscular anomalies, and 
latent muscular anomalies. The first group comprises 
the several varieties of squint — convergent, divergent, 
and vertical; the second group, the different varieties of 
heterophoria, or insufficiency of the ocular muscles — 
esophoria, exophoria, and hyperphoria. The essential 
difference between the two is that in the one case 
there is a sacrifice of binocular vision, while in the other 
binocular vision is maintained, but only at the cost of a 
constant struggle against an ever-present tendency to 
squint. 

Again, the muscular anomalies of the eyes may be 
divided, with reference to their etiology, into those of 
paralytic origin, those of congenital origin, and those 
dependent upon defects in the conformation of the eye 
— upon refractive errors. 

The anomalies of paralytic origin commonly belong 
to the first major group, though, as improvement in the 
palsy occurs, the squint may disappear, and they may 
pass over into the second group, to remain there for a 
shorter or longer time or, it may be, permanently. The 
anomalies of congenital origin, for the most part, belong 
to the second group, though, exceptionally, they may 
give rise to actual squint. The anomalies due to errors 
of refraction constitute a very considerable part of both 
major groups. 

438 



MUSCULAR ANOMALIES OF THE EYES. 439 

The manifest muscular anomalies — the actual squints 
— are not, in themselves, provocative of eye-strain, of 
asthenopia, but are of moment chiefly because of the 
deformity which attends them, and because the squint- 
ing eye usually becomes rapidly amblyopic. When they 
are of paralytic origin, and, therefore, develop suddenly, 
they are also commonly attended by very annoying 
diplopia and by vertigo. On the other hand, the latent 
anomalies, while they have no cosmetic significance, are 
of moment because of the marked asthenopic symptoms 
to which they give rise. The asthenopia is the expres- 
sion of the constant effort required to maintain binocular 
vision, in the presence of a disposition to squint; the 
establishment of the squint means the abandonment of 
this effort, and frequently results in the disappearance 
of the asthenopia. 

Squints provoked by errors of refraction are lateral 
squints, and, according to the nature of the refractive 
fault, the misdirected eye may turn in or out, the squint 
may be convergent or divergent. Convergent squints, 
as has been explained in the preceding chapter, are usu- 
allv associated with, and in most instances are depen- 
dent upon, hypermetropia, and commonly develop in 
early childhood. Divergent squints are oftenest asso- 
ciated with myopia, and may develop at any period of 
life. 

Squints due solely to muscular faults of congenital 
origin, as has been said, are rare; but when such mus- 
cular faults happen to be associated with refractive 
errors they may, and often do, play an important part 
in the production of squint. 

Paralytic squints may occur at any age, and, depend- 
ing upon the muscle involved, the squinting eye may 
turn in or out, upward or downward. To a proper 



440 



PREVALENT DISEASES OF THE EYE. 



comprehension of squints of this character familiarity 
with the nervous supply of the extrinsic muscles of the 
eye is essential. 

MANIFEST MUSCULAR ANOMALIES, 
Paralytic Squint. — It will be recalled that no less 
than three of the cranial nerves are distributed to the 
extrinsic ocular muscles (Fig. 157). The abducens, or 




Fig. 157. — The ocular muscles — the recti muscles, a, b, c, d, separated from 
their attachments at the apex of the orbit, the bony attachment of the inferior 
oblique muscle (/), and the trochlea of the superior oblique (e), diagram- 
matically represented (Nunneley). 

sixth nerve, supplies the external rectus; the trochlear, or 
fourth nerve, the superior oblique; and the oculomotor, or 
third nerve, all the other external muscles of the eyeball, 
as well as the levator of the upper lid, the ciliary mus- 



MUSCULAR ANOMALIES OF THE EYES. 44I 

cle, and the sphincter pupillae. From this it follows 
that but a single muscle is affected in paralysis of the 
fourth or sixth nerve, but that many are involved, or 
may be involved, in paralysis of the third nerve. In 
complete paralysis of any one of these three nerves a 
squint develops, and, as has been said, is attended by 
very annoving diplopia. If the paralysis is incom- 
plete, the squint and the diplopia may manifest them- 
selves only when an effort is made to turn the eyes 
in the direction of the affected muscle. Under any 
circumstances the diplopia disappears when either 
eve is excluded from vision. The sudden occurrence 
of diplopia, which can be gotten rid of by the exclusion 
of one eve, is an almost certain indication of paraly- 
sis of some one of the extrinsic eye muscles. The 
squint which attends the paralysis results, as a matter 
of course, from the unrestrained action of the opponent 
muscle. Paralytic squints, .as a rule, can be distin- 
guished from concomitant squints (those due to refrac- 
tive errors) by the fact that the squint increases in degree 
when the eves are turned toward the faulty muscle. 
An inability to rotate the affected eye in the direction of 
this muscle is also usually evident; though, in incom- 
plete paralysis, this is not always demonstrable. 

Paralysis of the ocular muscles (Fig. 158) arises from 
a variety of causes, and may be central or peripheral in 
its origin. Acquired syphilis is one of the commonest. 
Among other causes mav be mentioned disease of the 
central nervous system, locomotor ataxia, for example, 
rheumatism, influenza, diphtheria and other acute affec- 
tions, diabetes, renal and vascular disease, "cold," 
traumatism, tumors, orother coarse pathological changes, 
within the cranial cavity, and similar pathological pro- 



442 PREVALENT DISEASES OF THE EYE. 

cesses involving especially the apex of the orbit, through 
which the nerves pass in their course to the eye. 

In paralyses of intracranial origin, the lesion may be 
cortical, or it may involve the association centers, the 
nerve nuclei, the fibers which connect these centers, 
or, finally, the nerve-trunks in their course along the 
base of the brain. Although the lesion may develop as 
a primary affection, it is much more frequently the re- 




K 

Fig. 158. — Lateral view of the ocular muscles (Nunneley). The external 
rectus (h) is divided, so as to show the attachments of the oblique muscles 
(i, k) to the eyeball. The attachments of the four recti muscles (e, /, g, h), 
the superior oblique (i), and the levator palpebrae (d) at the apex of the orbit 
are also shown. 

suit of pathological processes in neighboring structures, 
which involve secondarily, by compression or otherwise, 
the nerves or their nuclei. In orbital paralyses, the 
nerve-lesion may be primary, the result of exposure to 
cold, for example, or it may be secondary to other dis- 
ease, such as periostitis or gumma at the apex of the 
orbit. 

Paralysis of the External Rectus Muscle {Paralysis of 
the Sixth Nerve). — This is the commonest of the ocular 



MUSCULAR ANOMALIES OF THE EYES. 443 

palsies. The lesion is usually orbital — an inflammation 
of the nerve itself or of its sheath — and is commonly the 
result of exposure to cold. If the paralysis is complete, 
there will be an easily recognised inward squint of the 
affected eye (Fig. 159), which will become more pro- 
nounced if an effort is made to rotate the eyes in the 
direction of the paralyzed muscle. Slight pain in the 
region of the orbit or one-sided headache may be com- 
plained of, but the chief complaint will be of diplopia, 
which is commonly attended by vertigo and not infre- 
quently by nausea. If the paralysis is incomplete, the 





Fig. 159. — Convergent strabismus (Dalrymple). 

squint will be evident, and the diplopia will manifest 
itself, only when the eyes are turned toward the affected 
muscle. Closure of either eye will cause the diplopia to 
disappear. The affection is nearly always unilateral, and 
the prognosis is distinctly favorable. 

Treatment. — The most efficacious remedy is potas- 
sium iodid in moderate — five- to ten-grain — doses. 
In conjunction with this strychnin may be given. The 
application of a blister to the temple has also seemed 
to me to be beneficial. In order to get rid of the annoy- 
ance caused by the diplopia, the affected eye should be 
excluded from vision by means of a patch or a ground 
glass. 



444 PREVALENT DISEASES OF THE EYE. 

Paralysis of the Superior Oblique Muscle {Paralysis 
oj the Fourth Nerve). — This is much less common than 
paralysis of the external rectus, and is not so easily diag- 
nosticated. Although it may arise from any of the 
causes mentioned as capable of producing ocular palsies, 
in its etiology and pathology it usually resembles the 
affection just described, and the prognosis is equally 
favorable. 

As the action of the superior oblique, besides rotating 
the eye about its sagittal axis so that the upper extremity 
of the vertical meridian is inclined inward, is to turn 
the eye downward and outward, the diplopia and squint 
which attend paralysis of this muscle are more marked, 
or may occur only, on looking down As this is true 
also of paralysis of the inferior rectus, the differentiation 
of the two conditions is to be made only by carefully 
taking into account the character of the diplopia, 
whether the images are "crossed" or "homonymous," 
and whether the "false image" tilts toward or away 
from the median line; but as such tests do not fall 
within the province of the general practitioner, a de- 
tailed description of them may be omitted, especially as 
the treatment of the two conditions is essentially the 
same. 

Treatment. — The therapeutic measures recommended 
in paralysis of the external rectus are indicated. 

Paralysis of the Oculomotorius or Third Nerve. — Next 
to paralysis of the sixth nerve, this is the commonest of 
the ocular paralyses. It is oftenest dependent upon 
acquired syphilis, is occasionally bilateral, and is not 
infrequently accompanied by palsy of other motor 
nerves of the eye. When all the branches of the nerve 
are involved a striking and very characteristic picture 
is exhibited. From loss of power of the levator palpebral 



MUSCULAR ANOMALIES OF THE EYES. 445 

the upper lid droops, and cannot be elevated (ptosis) 
(see Fig. 36). The pupil is semidilated and near vision 
greatlv impaired, because the sphincter pupillae and the 
muscle of accommodation are paralyzed; and, as all 
the extrinsic eve-muscles, except the external rectus 
and the superior oblique, are affected, there is a down- 
ward and outward squint, with inability to turn the eye 
upward, inward, or directly downward. Diplopia is 
not complained of because the drooping lid excludes 
the affected eve from participation in vision; it becomes 
manifest, however, when the lid is held up. If the 
fourth and sixth nerves are also involved there will be 
inability to move the eye in any direction, and, especially 
in this condition, known as ophthalmoplegia totalis, 
there will be marked exophthalmos, since the eyeball 
is deprived of the restraining influence of all of the recti 
muscles. 

Not infrequently only the extrinsic muscles supplied 
by the third nerve are affected, and the intrinsic mus- 
cles, the sphincter pupillae and the ciliary muscle, es- 
cape. This type of paralysis, known as ophthalmo- 
plegia externa, is necessarily of nuclear origin, and finds 
its explanation in the fact that the nuclei for the sphinc- 
ter pupillae and the ciliary muscle lie appreciably in front 
of those for the extrinsic muscles. For the same reason 
it may happen that the extrinsic muscles escape, while 
only the intrinsic muscles are involved. This consti- 
tutes the condition known as ophthalmoplegia interna, 
and is characterized by mydriasis and loss of power of 
accommodation. Diphtheria is oftenest responsible for 
this type of ocular paralysis, which has been considered 
in the preceding chapter, in treating of "anomalies of 
accommodation." Isolated paralysis of other muscles 
supplied by the third nerve is observed, but more rarely. 



446 PREVALENT DISEASES OF THE EYE. 

It may result from orbital disease, or may be congenital 
in origin. Congenital ptosis, from paralysis or imper- 
fect development of the levator palpebral superioris 
(see Fig. 35), is a familiar example. It is usually bilat- 
eral, and is at times accompanied by congenital para- 
lysis of the superior recti. 

The prognosis in paralysis of the third nerve, espe- 
cially when the affection is of luetic origin, is favorable, 
provided the requisite therapeutic measures are em- 
ployed without delay. 

Treatment. — Mercury and potassium iodid are, of 
course, the chief reliance in cases due to syphilis, and 
the latter is useful in other types of the disease. Strych- 
nin may be given in combination with either of these 
agents, and some authorities have faith in the efficacy 
of electricity. 

Operative procedures for the correction of paralytic 
squints and acquired ptosis are not to be resorted to 
hastily. Indeed, they should be employed only after 
other measures have been tried thoroughly, and have 
proved of no avail. 

Conjugate, or Associated, Ocular Paralyses.— 
This interesting form of ocular palsy results from 
lesions which involve the centers for the associated 
movements of the eyes — the convergence center, for 
example, which presides over the conjoint action of the 
internal recti muscles, or the center which controls 
the conjoint action of the internal rectus of one eye 
and the external rectus of the other, and has to do 
with the lateral movements of the eyes. A lesion 
of the first-named center will annul the associated 
action of the internal recti, though these same muscles 
will act normally in rotating the eyes to the right or 
left. On the other hand, a lesion of the center for 



MUSCULAR ANOMALIES OF THE EYES. 447 

the lateral movements of the eyes will prevent their 
being turned toward the affected side, though the con- 
vergence movement remains intact. This latter con- 
dition usually leads to a more or less marked deflection 
of the eves toward the unaffected side — conjugate devi- 
ation of the eyes. Conjugate paralyses are usually the 
result of destructive lesions of the brain, particularly 
cerebral hemorrhage. 

The prognosis depends upon the seriousness of the 
cerebral lesion, to which the treatment is to be directed. 

Nystagmus. — This affection, in which there is a 
rapid, oscillatory movement of the eyes, usually lateral, 
but more rarely vertical or rotary, is commonly of con- 
genital origin. It is met with also as an acquired con- 
dition, and then usually develops in infancy or early 
childhood. An interesting form of acquired nystagmus 
occurs in miners, as a result of the abnormal conditions 
to which their eyes are subjected. 

Congenital nystagmus, and this is true also of the 
nystagmus acquired in early childhood, is commonly 
associated with other congenital ocular defects, such as 
zonular cataract, coloboma of the choroid, corneal 
opacities, albinism, refractive errors of high grade, etc. 
Like the conjugate paralyses just described, this affec- 
tion also is dependent upon an abnormal condition of 
the centers which preside over the associated move- 
ments of the eyes. 

Although from a cosmetic point of view nystagmus 
is of moment, it seems, of itself, except, perhaps, in the 
case of miner's nystagmus, to give rise to no subjective 
inconvenience. It may be added in parenthesis, how- 
ever, that it is the bete noire of the ophthalmoscopist and 
of the "refractionist," so called. 

Treatment. — Little can be done for the amelioration 



448 PREVALENT DISEASES OF THE EYE. 

of congenital or early acquired nystagmus, except to 
correct carefully any refractive fault that may be pres- 
ent. Miner's nystagmus may disappear in time as a 
result of a change of occupation. 

Concomitant Squint (Strabismus Concomitans). 
— A concomitant squint, as opposed to a paralytic 
squint, is one in which the squint remains constant in 
degree in whatever direction the eyes may be turned; 
that is, the squinting eye always follows the movements 
of the fixing eye. In paralytic squint, as has been ex- 
plained, this is not the case. The squinting eye does 
not follow in all directions the movements of the fixing 
eye, and therefore the squint varies in amount, increas- 
ing when the eyes are turned in the direction of the 
paralyzed muscle, and diminishing or, perhaps, disap- 
pearing when they are turned in the opposite direc- 
tion. 

The misdirected eye in concomitant squint may turn 
in or out, upward or downward, or it may squint both 
vertically and laterallv. The squint may be constant, 
or it may be inconstant, or periodic, as it is termed. It 
may affect always the same eye, or it may be alternating 
— may shift from one eye to the other. It is never bi- 
lateral, since one or the other eye must necessarily be 
directed toward the object regarded. Diplopia is rarely 
complained of in concomitant squint, because, in the 
first place, the fault usually develops in early childhood, 
and, in the next place, in the young the habit of mentally 
suppressing the image formed in the squinting eye is 
very quickly acquired. 

Reference has already been made to the causes of 
concomitant squint. Enumerated in the order of their 
importance, they are: anomalies of refraction, congen- 
ital muscular defects (insufficiencies), acquired mus- 



MUSCULAR ANOMALIES OF THE EYES. 449 

cular defects. A marked difference in the visual acute- 
ness of the two eyes also tends to promote the develop- 
ment of squint, and so does a pronounced difference in 
their refraction. 

Apart from the deformity which attends it, the most 
serious consequence of concomitant squint is the ambly- 
opia of the squinting eye to which it gives rise. It is 
true, there are those who contend that the amblyopia 
nearly always found in the squinting eye (in non-alter- 
nating strabismus) is a cause, ratherthan a consequence, 
of the squint; but, to my mind, the evidence to the con- 
trary is so strong as to be practically conclusive.* 

It is a mistake to designate, as most writers do, the 
amblyopia of a squinting eye as " amblyopia exanopsia," 
for it is essentially different in its origin from this con- 
dition. As an example of true amblyopia exanopsia, 
or, in other words, of amblyopia from non-use of an eye, 
may be cited the impairment of vision which results 
from permitting a monocular, congenital cataract to 
remain too long unoperated upon. Under such cir- 
cumstances, the cataractous eye becomes amblyopic 
simply because its retina and optic nerve are not exer- 
cised as they should be. In concomitant squint some- 
thing very different from this occurs. In order to get 
rid of the diplopia, which at the outset necessarily mani- 
fests itself each time that the as-yet-not-fully-estab- 
lished squint recurs, an active mental effort is made to 
suppress the image formed upon the retina of the squint- 
ing eye; and in the young this effort proves so successful 
that in a comparatively short time the diplopia disap- 

* The author's views upon this point, and the grounds upon which 
they are based, are set forth in a paper "The Amblyopia of Squinting 
Eyes: Is it a Determining Cause or a Consequence of the Squint?" 
published in the "Medical News" of September 4, 1886, and in the 
"Trans, of the American Ophthalmological Society" for 1886. 
29 



450 PREVALENT DISEASES OF THE EYE. 

pears, and concurrently with this the sight of the squint- 
ing eyes becomes markedly impaired. 

As pointed out in the paper to which reference has 
been made, the regional character of the amblyopia 
found in squinting eyes is very significant, and affords 
strong evidence in support of the view that it is an ac- 
quired, and not a congenital, condition, and that it is 
produced in the manner just described. 

If we ask, what must be the chief sources of annoy- 
ance to an individual who has just begun to squint, we 
must conclude that he has two especial difficulties to 
contend with — one, the doubling of every object upon 
which he fixes his attention, in consequence of the 
"false" position of the retinal image of this object in 
the squinting eye; the other, the confusion of vision 
which must result from the images of different objects 
falling upon the macular region of the two eyes. 

To get rid of these annoyances he has a twofold 
task to accomplish: To eliminate the diplopia, 
he must induce that part of the retina of the 
squinting eye that habitually receives the false image 
of the object he is regarding with the other eye not to 
take cognizance of this image; to prevent the image of 
some object which he is not regarding from being (men- 
tally) superposed and fused with the object which he is 
regarding, he must ignore all images formed upon the 
macula of the squinting eye. The successful accom- 
plishment of this task will result in the production of an 
amblyopia in the squinting eye regional in character — 
most marked (i) in the neighborhood of the macula and 
(2) in that portion of the retina which receives the false 
image of the object regarded by the properly directed 
eye. Now, as a matter of fact, the amblyopia found in 
squinting eyes does exhibit just these characteristics, 



MUSCULAR ANOMALIES OF THE EYES. 45 1 

and this circumstance seems to afford, as I have said, 
almost conclusive proof that the defect is not a con- 
genital one, but is a product of the squint.* 

This question of the origin of the amblyopia of squint- 
ing eyes is one not merely of theoretical interest, but of 
practical importance; for, if it can be established that 
the amblyopia is a consequence of the squint, the advis- 
ability of early operation would hardly be open to doubt. 

It is a fortunate circumstance when a squint shows 
a disposition to alternate, or when, as sometimes happens, 
the eye which squints in distant vision is the fixing 
eye in near vision, and vice versa; for, under such cir- 
cumstances, both eyes usually retain good vision. A 
marked difference in the refraction of the two eyes also 
has a tendency to lessen the likelihood of the squinting 
eye becoming amblyopic, because the retinal image in 
this eye, being ill-defined, causes less annoyance, and 
for this reason is not so energetically "suppressed." 

Concomitant squint is always alternating in the sense 
that if the fixing eye is covered the squint shifts to this 
eye, and the other eye, for the moment, becomes the 
fixing eye. It is true the fixation with this eye is often 
uncertain, and may be eccentric, because of its regional 
amblyopia. The "secondary" squint thus induced 

* It is an interesting fact, and one having an important bearing 
upon the question under consideration, that when a squint, which for 
years has been unattended by diplopia, is over-corrected by too free 
tenotomizing — so that, for example, a convergent squint is converted 
into a divergent one — a persistent and annoying diplopia not infre- 
quently manifests itself. The explanation, of course, is that owing to 
the change in the direction of the squint the false image now falls upon 
an entirely different part of the retina, a part which has not learned to 
ignore images formed upon it, and, therefore, is not amblyopic. The 
diplopia which it is usually possible to produce in a strabismic indi- 
vidual by causing the false image of a candle flame, by means of a 
prism, to fall upon an unusual part of the retina is to be explained in 
the same way, and is equally significant. 



452 PREVALENT DISEASES OF THE EYE. 

in the usually properly directed eye commonly equals 
in degree the "primary" squint; but, especially in con- 
vergent strabismus, it is not infrequently greater in 
amount, because the ciliary muscle of the squinting eve 
is not exercised as habitually as that of the fixing eye, 
and must, therefore, put forth a greater effort in order 
to obtain a sharply defined retinal picture. The result 
is the same when the refractive error is considerably 
greater in the squinting eve. On the other hand, when, 
as is seldom the case, the refractive error in this eve is 
considerably less than in the fixing eve the secondary 
squint may be less than the primary. 

The detection of a pronounced squint is not a difficult 
matter; but, if one relies solely upon "appearances/' 
it is easy to fall into error. For not only is it often im- 
possible to recognize in this way slight degrees of squint, 
but there is a simulation of convergent squint in myopia 
of high grade, and of divergent squint in hvpermetropia 
of like character, "calculated" to deceive even the elect. 

The "cover-test" affords, except when the fault is 
very slight in degree, a trustworthy means of determin- 
ing the existence or non-existence of squint, and it is not 
difficult of application. The patient, with both eyes 
open, is directed to gaze fixedly upon a candle-flame 
ten to twenty feet away. The supposedly fixing eve is 
then covered quickly with a small screen, while the other 
eye is watched closely to see if it moves, in order to "fix" 
the flame. If it has been squinting previously it is ob- 
vious that it must make a "movement of correction," 
as it is termed, in order to look directly at the candle- 
flame. In very low degrees of squint this correcting 
movement is so slight that it may be difficult to detect; 
but, except under such circumstances, it is easily ob- 
served, and when observed the existence of a squint is 



MUSCULAR ANOMALIES OF THE EYES. 453 

proved. The direction of the movement will show the 
character of the squint — whether it is convergent, di- 
vergent, or vertical. 
Convergent Concomitant Squint or Strabismus. — 

This is the commonest variety of concomitant squint (see 
Fig. 159). It nearly always develops in early childhood, 
when the eyes are beginning to be used in regarding 
near objects, and, except in rare instances, it is found in 
association with hypermetropia or hypermetropic astig- 
matism. Its etiology, and the role which hypermetro- 
pia plays in its production, have been considered in the 
preceding chapter (pages 396 and 397), in treating of 
the ill consequences of that refractive fault. 

Donders, who, so far as the anomalies of refraction 
are concerned, brought order out of chaos, was 
the first to recognize the intimate dependence of 
concomitant convergent squint upon hypermetropia. 
He, of course, realized that hypermetropia is a 
far more common condition than convergent squint, 
and he explained this fact — why some hypermetropes 
squint and so many do not — in a thoroughly satisfactory 
manner.* The desire for binocular vision and the 
abhorrence of diplopia, he tells us, suffice to prevent the 
occurrence of squint in the great majority of hyperme- 
tropes. Weakness of the internal recti muscles and, 
he might have added, exceptionally energetic accommo- 
dative power, tend to the same end. Among conditions 
conducing to its occurrence he mentions congenital 
weakness of the external recti muscles, congenital or 
acquired difference in the visual acuteness or the refrac- 
tive condition of the two eyes, and the exceptionally 
large value of the angle alpha (the angle formed by the 

* "The Anomalies of Accommodation and Refraction of the Eye," 
pp. 294 et seq. 



454 PREVALENT DISEASES OF THE EYE. 

visual line and the axis of the cornea) in hypermetropia. 
And, again, he might have added, inefficient, or subnor- 
mal, accommodative power. 

It is evident why weakness of the internal recti mus- 
cles, and why exceptional power of accommodation, in 
association with hvpermetropia, should render the occur- 
rence of convergent squint less probable; and why insuffi- 
ciencv of the external recti muscles and subnormal ac- 
commodative power should favor its development. 
And since the advantages of, and the desire to maintain, 
binocular vision, as well as the annoyances arising from 
diplopia, are greatly lessened by the existence of a 
marked difference in the acuteness of vision or the re- 
fraction of the two eyes, it is not difficult to comprehend 
why each of these conditions should have a like effect. 
As to the influence exerted bv a large angle alpha, it 
must be admitted that it is not so obvious. 

What has been said as to "periodic" and "alternat- 
ing" squint applies especially to the variety of squint 
under consideration. There can be little doubt that 
most cases of concomitant convergent squint, at the out- 
set, are periodic, and the cases which remain so per- 
manently are nearly always of this type, and this is true 
also of the majority of cases of alternating squint. 

Although so frequently found in association with hy- 
permetropia, concomitant convergent squint occurs, 
exceptionally, in myopia of high grade. In these seem- 
ingly anomalous cases there is, in the first place, doubt- 
less a congenital lack of balance between the external 
and internal recti muscles — the former being insuffi- 
cient and the latter possessing unusual strength. Then, 
it commonly happens that this type of squint is en- 
countered in myopes who have used their eyes a great 
deal in near vision, without correcting glasses, holding 



MUSCULAR ANOMALIES OF THE EYES. 455 

the printed page, for example, very close to the eyes, 
and reading with forced convergence. The effect of 
this habitual overaction of the internal recti, and the 
attendant stretching of the externi, is to exaggerate the 
preponderance of the former, until finally there comes 
a time when, in regarding distant objects, the visual axes 
can not be brought into proper relation, and a con- 
vergent squint, which often continues to manifest itself 
only in distant vision, is established. 

Treatment. — In view of the disfigurement which at- 
tends convergent squint, and the serious impairment of 
vision which nearly always results in the deviating eye, 
there seem to be the best of reasons why the defect 
should be corrected, with as little delay as possible; 
and, it may be added, there are few cases in which this 
can not be done, provided the remedial measures indi- 
cated are employed as promptly as they should be. 

These measures consist in the adjustment of glasses 
for the correction of the usually present refractive fault, 
and in operative procedures upon the ocular muscles. 
And here it may be well to state, parenthetically, that, 
in view of the interdependence of the two conditions, no 
one who is incapable of accurately determining and cor- 
recting refractive anomalies is justified in operating for 
concomitant squint. 

Only in exceptional instances can concomitant con- 
vergent squint be dealt with satisfactorily, without the 
aid of glasses. Whether it can be corrected by glasses 
alone, without operation, depends largely upon the 
character and duration of the squint, as well as upon 
the degree of the refractive error and the visual acute- 
ness of the deviating eye. As a general truth, it 
may be said that when a squint has passed the 
periodic stage, and has become firmly established, 



456 PREVALENT DISEASES OF THE EYE. 

it is seldom possible to correct it without opera- 
tion. The cases likely to prove exceptions to this rule 
are those in which hypermetropia of high grade exists, 
with comparatively good central vision in the deviating 
eye, such as is usually found in alternating squint. On 
the other hand, when the squint is still in the formative 
stage, is still periodic in character, it is always possible 
to correct it by glasses alone; although, even under such 
circumstances, an operation may be indicated to im- 
prove the muscle-balance and relieve asthenopic symp- 
toms In every case of squint, whether an operation 
is to be performed or not, a cycloplegic should be em- 
ployed, and the refractive condition and visual acute- 
ness of each eye should be carefully determined. If 
astigmatism is present it, as well as the general refrac- 
tive fault, must be corrected. 

The ideal result aimed at in the treatment of squint 
is the re-establishment of binocular vision. Whether 
this can be accomplished or not depends, in great meas- 
ure, upon the character and degree of the amblyopia 
in the deviating eye. In some instances, too, we have 
to contend with a positive disinclination to fuse images 
formed in the two eyes upon identical retinal points. 
As a result of operation the muscle-balance may be 
practically normal, and yet the squinting eye may show 
no inclination whatever to "fix" the object which the 
properly directed eye is regarding. The condition is 
a discouraging one, and can seldom be overcome. Sys- 
tematic exercise of the vision of the eye which is at fault, 
the other being carefully excluded, offers the only hope of 
accomplishing this. If, on the other hand, the sight of the 
deviating eye is not greatly impaired, and an inclination 
to binocular fixation exists, the ideal result spoken of 
can in most instances be attained. In securing this 



MUSCULAR ANOMALIES OF THE EYES. 45/ 

result we are greatly aided often by combining esophoric 
prisms with the lenses which correct the refractive 
error. 

As to the operative procedure best adapted to the cor- 
rection of convergent squint there is not a unanimity 
of opinion. There are those who prefer the operation 
of advancement, though the great majority of ophthal- 
mic surgeons prefer tenotomy. My own decided pre- 
ference is for tenotomy, and I resort to advancement 
only exceptionally, and usually to increase the effect 
of a previously performed tenotomy. The advantages 
of tenotomy are that it is a simpler procedure, involving 
considerably less traumatism and much less pain than 
advancement; that its effect can be more exactly 
gauged; that, if necessary, it can be repeated more 
readily; and that it accomplishes the end in view, at 
least, as satisfactorily. 

Of the several methods of performing tenotomy the 
simplest — the operation of Arlt — it seems to me, 
is decidedly the best, since it is the easiest to execute 
and the least painful, and its effect can be graduated 
with much precision. For its performance there are 
required a speculum * (Fig. 160), a pair of straight, 
slightlv blunt-pointed scissors (Fig. 161), a strabismus- 
hook (Fig. 162), and delicate straight forceps, with teeth 
— two on one blade and one on the other — that project 
but slightly (Fig. 163). If the conjunctival wound is to 
be closed by a stitch, a curved needle and a suitable 

* This speculum, contrived by the late Dr. Russell Murdoch, of 
Baltimore, should be used far more generally than it is. Especially 
for delicate operations, such as extraction of cataract, it is, in my opin- 
ion, decidedly the best speculum that we have. Its advantages are 
that it is self-locking, that it exerts a minimum degree of pressure upon 
the eye, that it can be easily and quickly removed from between the 
lids, and that it affords an exceptionally unobstructed field to the 
operator. 



458 



PREVALENT DISEASES OF THE EYE. 



needle-holder (Fig. 164) should also be provided. The 
steps of the operation are as follows: The speculum 




Fig. 160. — Murdoch's self -locking speculum (about two-thirds actual size). 




Fig. 161. — Strabismus scissors. 




Fig. 162. — Author's crochet-pointed strabismus hook: a, Actual size of hook; 
b, enlarged view of crochet point. 




Fig. 163. — Strabismus forceps. 



having been introduced, the conjunctiva just over the 
insertion of the tendon to be divided is seized with the 



MUSCULAR ANOMALIES OF THE EYES. 



459 



forceps, care being exercised not to include in their 
grasp the underlying fascia, and with the scissors a 
vertical incision, somewhat less than I cm. in length, 
is made in the slightly elevated conjunctiva 
(Fig. 165). The points of the scissors are next 
introduced through this opening, and the conjunc- 
tiva is rather widely separated from the underlying 
fascia. This step is especially important in oper- 
ating upon the rectus internus, because, if it is done thor- 
oughly, — the scissor-points being carried well toward 
the inner canthus — the unsightly sinking of the caruncle 




Fig. 164. — Author's needle-holder. 



so often observed in awkwardly executed tenotomies 
is entirely obviated. The exposed tendon is now seized 
just back of its attachment, is somewhat elevated, and 
is separated from the sclera by a few snips of the scissors 
(Fig. 166). If the tenotomy is intended to produce only 
a moderate effect, the operation, except for the closure 
of the conjunctival wound, may stop at this point; but if, 
as is usually the case in operations for squint, a more de- 
cided effect is desired, the incision, previously limited to 
the tendon, must be extended, both upward and down- 
ward, through Tenon's capsule. And here, for the first 



460 



PREVALENT DISEASES OF THE EYE. 



time, to facilitate this last step of the operation, it becomes 
necessary to use the strabismus-hook. And this is one 
of the chief advantages of Arlt's operation, for the 
manipulations with the hook are more apt to cause 




sTu«.i,«U 



Fig. 165. — Tenotomy of the internal rectus of the right eye by Arlt's 
method. The first step of the operation — the conjunctival incision — com- 
pleted, exposing the tendon. 




Fig. 166. — Dissection of the tendon from its scleral attachment. (The- 
operator is standing behind the patient.) 



pain than the actual cutting with the scissors, and 
therefore it is desirable that it should be employed as. 
little as possible. 

The conjunctival wound is now brought together by 



MUSCULAR ANOMALIES OF THE EYES. 



461 



means of a single stitch of fine black silk (Fig. 167) — 
except in young children, because with them the removal 
of the stitch is usually attended with considerable diffi- 
culty — and a light compress bandage is applied (see Fig. 
10). On the following day the bandage is dispensed 
with, and after three days the stitch is removed. 

With the eye thoroughly under the influence of cocain, 
and with delicacy of manipulation, this operation in 
most instances is practically painless. In children, 
simply because it is impossible otherwise to control 




Vv_ 



i.^.j^U- 



Fig. 167. — The operation completed. Conjunctival wound closed by 
single black-silk suture. 



their movements, general anesthesia is required; but 
with adults this is never necessary. Alternating with 
the applications of cocain, it is advantageous to make a 
few instillations of a 1 : 1000 adrenalin solution, as this 
lessens, and sometimes entirely obviates, hemorrhage, 
besides increasing the anesthetic action of the cocain. 
Since in skilful hands, and with proper antiseptic 
precautions, the operation may be said also to be 
practically without risk — infection being almost unheard 
of — there seems to be no good reason why it should 



462 PREVALENT DISEASES OF THE EYE. 

not be resorted to whenever there is a clear indication 
for its performance. 

Should the cutting of a single muscle leave, as it often 
does, a residual squint, either of two courses may be 
adopted. The internal rectus of the opposite eye may 
be tenotomized somewhat less freely, or an endeavor 
may be made to overcome the residual defect by correct- 
ing the usually present refractive error and combining 
esophoric prisms with the required lenses. The latter 
course is to be preferred, if the residual squint is slight 
and the refractive error of high degree; the former, if 
there is still a decided squint left, and especially if there 
is not a considerable amount of hypermetropia to be 
corrected. 

In former times, when operations for squint were 
done in clumsy fashion, — the muscle being divided at a 
considerable distance behind its point of attachment to 
the sclera, — and the refractive state of the eyes was ig- 
nored, it frequently happened that the eye operated 
upon "went the wrong way," as it was expressed, a 
scarcely less unsightly divergent squint being substi- 
tuted for the previously existing convergent squint. In 
consequence of this the operation fell into well-deserved 
disrepute, which to the present day it has not entirely 
outgrown. It is scarcely necessary to point out that 
the modern operation is a wholly different procedure, 
and that in skilful hands it is attended by no such 
risk. 

It only remains to add that the earlier a convergent 
squint can be corrected the better; since, other things 
being equal, the longer it is allowed to exist the greater 
will be the amblyopia of the squinting eye. We are 
unquestionably handicapped in operating at so early an 
age that the help afforded by glasses can not be availed 



MUSCULAR ANOMALIES OF THE EYES. 463 

of; but, notwithstanding this fact, I believe more is lost 
than is gained by postponing operation. 
Divergent Concomitant Squint or Strabismus. 

— In the preceding chapter it has been pointed out 
that myopia plays almost as important a role in the 
causation of divergent squint (Fig. 168) as hypermetropia 
does in that of convergent squint, and an explanation 
of how this occurs has been given. The importance of 
this influence is shown by the fact that myopia exists in 
about two-thirds of all cases of divergent squint. Other 
factors which conduce to the development of this variety 
of strabismus are congenital or acquired insufficiency 




Fig. 168. — Divergent strabismus (Dalrymple). 

of the internal recti muscles and marked difference in 
the visual acuteness of the two eyes. 

When, from any cause, the sight of one eye is 
decidedly impaired, so that the advantages of, and the 
disposition to maintain, binocular vision are in large 
measure lost, the defective eye is prone to squint in 
one direction or another. It will squint inward, if the 
external recti muscles are relatively weak, or if the better 
eye is decidedly hypermetropic. On the other hand, if 
there is insufficiency of the internal recti or the better 
eye is myopic, a divergent squint is very apt to occur. 
Unlike convergent squint, divergent squint, which is 



464 PREVALENT DISEASES OF THE EYE. 

less common, usually develops in adults, and is observed 
only exceptionally in children. 

In myopia of considerable degree, because of the 
nearness of the far-point of distinct vision and the 
altered relation of accommodation and convergence, the 
difficulty of maintaining binocular fixation is greatest 
in near vision, as in reading, writing, etc. For this 
reason it often happens that the squint manifests itself 
at first only when near objects are regarded. Indeed, 
it is not uncommon for it to continue to occur only under 
such circumstances, binocular fixation being maintained 
in distant vision. At the outset the squint is usually 
periodic, and only after a considerable time becomes 
constant. It is seldom alternating, except in the sense 
that one eye may be used in distant, the other in near, 
vision. In divergent concomitant squint, probably 
because the true and false images are usuallv so far 
apart, there is but little complaint of diplopia, and for 
this reason, and because the defect, seldom develops in 
childhood, the regional amblvopia characteristic of 
the convergently squinting eve is rarely observed. 

Treatment. — Only exceptionally is it possible to cor- 
rect a divergent squint without operation. The cases 
in which this may be accomplished are usually those in 
which a marked difference exists between the refractive 
condition of the two eyes, or in which the squint is asso- 
ciated with myopia of considerable degree, and occurs 
only in near vision. In the condition first mentioned 
the blurred image formed upon the macula of the more 
ametropic eye proves a source of annoyance, and the 
squint may be the expression of a desire to get rid of this 
annoyance rather than a result of the existence of decided 
muscular imbalance. If, therefore, by means of glasses 
the vision of each eye can be brought up to about the 



MUSCULAR ANOMALIES OF THE EYES. 465 

same standard, the squint not infrequently will dis- 
appear, and the eyes thereafter will work in harmony.* 
In the cases associated with myopia of considerable 
degree, in which the squint occurs only in near vision, 
glasses that correct a part of the near-sightedness, by 
removing the far-point of distinct vision to a comfortable 
distance from the eyes, and by restoring more nearly 
the normal relation between accommodation and con- 
vergence, will render binocular fixation very much 
easier, and may cause the disappearance of the squint. 

Such cases, however, as has been said, are excep- 
tional, and, as a rule, the surgeon may congratulate 
himself if, even by the help of an operation, he is able 
to correct a divergent squint so exactly as to re-establish 
comfortable binocular vision. In high degrees of my- 
opia it is not always best to attempt this, for the progress 
of the myopia is often favorably influenced by the 
abandonment of binocular fixation and the convergence 
tension which it implies. 

Divergent squint can not so surely be corrected 
by tenotomy alone as can convergent squint. Not 
infrequently tenotomy of the external rectus must 
be supplemented by advancement of the internal rectus. 
However, free tenotomy of both external recti muscles, 
not, as a rule, performed at the same time, though this 
may be warrantable, often yields a very satisfactory 
result, even in cases in which the squint is pronounced. 
The procedure of Arlt, already described, it should be 
stated, is as well adapted to the correction of divergent, 
as it is to that of convergent, squint. In securing the 
effect desired glasses afford valuable assistance, espe- 
cially in myopic cases and in cases in which there is ani- 

* In the "Johns Hopkins Hospital Bulletin" for April, 1890, Vol. I, 
No. 4, the author has reported several cases of this character. 
3° 



466 PREVALENT DISEASES OF THE EYE. 

sometropia. With the lenses called for by the refractive 
fault exophoric prisms may often be combined with 
advantage. 

When the sight of the squinting eye is very defective, 
a lessening of the deformity is the most that can be 
hoped for from operation, since under such circum- 
stances the restoration of binocular vision is not to be 
expected. Even for this purpose, however, a tenotomy 
may be justifiable, since the cosmetic effect is often very 
gratifying. 

Vertical concomitant squint is rare, and is usu- 
ally the result of a precedent paralysis of one of the 
oblique muscles, or of one of the superior or inferior 
recti muscles. It is not uncommon, however, in both 
convergent and divergent squint, to find a considerable 
amount of vertical deviation associated with the lateral 
fault. 

Treatment. — Vertical squint can seldom be corrected 
without operation, and is more difficult to deal with than 
lateral squint, because, in the first place, glasses do not 
afford us the same help in securing the desired result, 
and, in the next place, we oan depend upon the eyes, 
themselves, for comparatively little assistance, since they 
are capable of overcoming but a slight residuum of ver- 
tical squint. 

LATENT MUSCULAR ANOMALIES. 

Under this head are included, as has been explained, 
all the varieties of heterophoria, or, in other words, all 
the muscular anomalies of the eyes, in which, despite a 
tendency to squint, binocular vision is maintained. 

Although heterophoric conditions, because less com- 
mon, are not so frequent a cause of asthenopia as are 
errors of refraction, they are quite as capable of pro- 



MUSCULAR ANOMALIES OF THE EYES. 467 

ducing the manifold symptoms, local and remote, which 
we have learned to attribute to eye-strain. Among the 
ocular disturbances to which they give rise may be men- 
tioned pain, intermittent blurring of vision,- — attended 
at times by diplopia, — conjunctival hyperemia, and 
blepharitis marginalis; among the more remote, head- 
ache, vertigo, nausea, neurasthenia, insomnia, and 
indigestion. When associated with ametropia, they 
may greatly aggravate the ill consequences of the refrac- 
tive fault; but, to their credit be it said, they may exert 
exactly the contrary effect, as, for example, when a not 
too considerable exophoria is associated with hyper- 
metropia, or a not too pronounced esophoria with my- 
opia. 

Of the several varieties of heterophoria — esophoria, 
exophoria, and hyperphoria — the last named, in which 
there is a tendency to vertical squint, is the one most 
sure to give rise to unpleasant consequences, since 
the eyes are less capable of coping with it successfully. 
However, both esophoria and exophoria often cause 
marked asthenopia, headache, etc., and the latter con- 
dition, when associated with myopia, exerts a further 
baneful influence, since it tends to promote the increase 
of the refractive fault. 

It has been stated that a very considerable part of the 
latent muscular anomalies of the eyes are due to errors 
of refraction. It is equally true that a not inconsider- 
able part are wholly independent of refractive errors. 
Those which belong to the first-mentioned class may 
properly be termed apparent, those which belong to the 
latter class actual, muscular anomalies. 

There are extremists who contend that refractive 
errors are responsible for all latent muscular anomalies, 
not of paralytic origin. There are other extremists who 



468 PREVALENT DISEASES OF THE EYE. 

hold exactly the opposite view, who belittle the influence 
which errors of refraction exert upon muscular faults, 
and who do not hesitate to tenotomize, let us say, the 
internal rectus for an apparent esophoria, without hav- 
ing determined, with even approximate accuracy, the 
refractive condition of the eyes. The truth lies be- 
tween these extremes. It seems, indeed, inexplicable 
that any one who has had experience in ophthalmic 
practice, and whose powers of observation are not below 
mediocrity, should, on the one hand, deny the reality of 
muscular insufficiencies, or, on the other, fail to recog- 
nize the important role which errors of refraction play 
in the causation of heterophoria. 

While it is true that refractive errors, when present, 
markedly influence real muscular faults, there are mus- 
cular faults, as has been said, which are in no sense de- 
pendent upon ametropia, and which are just as real as 
ametropia itself. Such faults, it may be admitted, are 
not very often met with in emmetropic eyes; but this 
circumstance finds its explanation in the comparative 
rarity of emmetropia. 

It is not a difficult matter to determine whether an 
observed muscular anomaly is actual or apparent. The 
first step, of course, is to ascertain the true refractive 
condition of the eyes, and to do this it is usually neces- 
sary to employ a cycloplegic. If the test fails to reveal 
the existence of ametropia, or if it shows an error of re- 
fraction incapable of producing the muscular anomaly, 
the reality of the latter is demonstrated. If, again, 
it reveals a refractive error which might be expected to 
cause the muscle-fault, this error must be corrected by 
glasses, and the test for muscular imbalance repeated. 
Should these tests now show a practically orthophoric 
condition, we may conclude that the muscular fault is 



MUSCULAR ANOMALIES OF THE EYES. 



469 



not real, that it is wholly the result of the ametropia. 
Should they, on the other hand, still show an appreciable 
amount of heterophoria, we are warranted in regarding 
this residual fault, at least, as being real. It should be 
added that the muscle-balance tests just mentioned 
should be made not only while the eyes are under the 
influence of the cycloplegic, but after they have re- 
covered fully from its effect. 

From what has been said as to the significance of the 
latent muscular anomalies of the eyes, and as to the ill 
consequences to which they give rise, it is evident that 
their determination and correction are of prime impor- 
tance ; that, in fact, they demand 
attention as imperatively as do 
the faults of refraction. 

As the determination of 
heterophoria does not fall with- 
in the province of the general 
practitioner, I have not thought 
it necessary to describe the 
muscle-balance tests to which 
reference has been made. I 
may say, however, in this con- 
nection, that I consider the simplest contrivances 
for measuring the muscle-balance the best, and that 
I have found no occasion to employ for this purpose 
cumbersome apparatus, such, for example, as the 
phorometer of Stevens. My chief reliance, in the 
determination of hyperphoria, is upon the multiple 
Maddox rod (Fig. 169) and, in the measurement of 
esophoria and exophoria, upon the modified vertical 
diplopia test of vonGraefe; and in applying these tests 
I make use of prisms taken from my trial case. The 
muscle-balance for near vision, I consider, should be 




Fig. 169. 



-Multiple Maddox 
rod. 



470 



PREVALENT DISEASES OF THE EYE. 



determined with as much care as for distance, and in 
doing this, especially in searching for hyperphoria, I 
have found the ''pin-hole'' light of Schild,* used in 
conjunction with the Maddox rod, of great assistance 
(Figs. 170 and 171). 




Fig. 170. — Schild's pin-hole electric light. 

The correction of heterophoria is to be accomplished 
by glasses or by operative procedure. If the muscle- 
fault is unreal, if it is dependent wholly upon an error 
of refraction, it will disappear with the correction of the 

* Described in "The Ophthalmic Record" for June, 1904, and 
made by Chas. A. Euker & Co., 312 N. Howard St., Baltimore. 



MUSCULAR ANOMALIES OF THE EYES. 4.JI 

ametropia. If it is real, prismatic glasses must be pre- 
scribed, or an operation performed — the former, if the 
fault is not marked; the latter, without hesitation, if it 
is pronounced. Although some ophthalmic surgeons 
are skeptical as to the advisability of operating for latent 
muscular anomalies, my own experience is that in suit- 
able cases much can be accomplished by operation; 
and here, as in squint, my preference is for tenotomy 
of the stronger, rather than for advancement of the 




Fig. 171. — Schild's pin-hole light as employed in the Maddox-rod test, at the 
reading distance. 

weaker, muscle, though exceptionally I deviate from 
this rule, especially in cases of marked exophoria. 

Exophoria (Insufficiency of the Internal Recti 
Muscles) . — Since myopia, as has been pointed out, plavs 
so important a part in the causation of both apparent 
and actual insufficiency of the internal recti muscles, 
a careful test of the refraction should be made in every 
case of exophoria. If the test reveals a considerable 
amount of myopia, and especially if the exophoria is 



472 PREVALENT DISEASES OF THE EYE. 

chiefly noticeable in near vision, the muscle-fault will 
often prove to be wholly, or in great part, unreal. If, on 
the other hand, it reveals emmetropia, and all the more 
if it shows hypermetropia or hypermetropic astigmatism, 
the reality of the muscular insufficiency is proved. 

Treatment. — If the exophoria is associated with my- 
opia, and is chiefly manifest in near vision, the partial 
or complete correction of the refractive error by glasses 
— the strength of the glasses to be determined not only 
by the degree of the myopia, but by the age and accom- 
modative power of the individual and the amount of the 
muscular defect — will usually eliminate the exophoria, 
or reduce it to a facultative degree. If this is not the 
case, exophoric prisms must be combined with the 
glasses selected for near vision. If the muscular fault 
is present in both distant and near vision, and, as usually 
happens under such circumstances, is not eliminated by 
the correction of the myopia, prisms for constant use 
must be prescribed, or, if the fault is of such a degree as 
to warrant it, a guarded tenotomy of the external rectus 
or an advancement of the internal rectus must be made. 

Exophoria occurring independently of myopia is 
susceptible of correction only by prisms or by operation. 
If it is not pronounced, or if it is present, as sometimes 
happens, only in near, or possibly only in distant, vision, 
the former method is indicated. If it is pronounced, 
and present in both far and near vision, a tenotomy of 
the external rectus of one or both eyes — a considerable 
interval, however, being allowed to elapse between the 
two operations — should be performed, and will com- 
monly prove markedly beneficial. In extreme cases, 
as has been intimated, advancement of one or both of 
the internal recti muscles may be combined with 
tenotomy of the externi. 



MUSCULAR ANOMALIES OF THE EYES. 473 

Esophoria (Insufficiency of the External Recti 

Muscles). — In the causation of esophoria hyperme- 
tropia and hypermetropic astigmatism play even a more 
important role than myopia does in that of exophoria, 
and, since these faults are so prevalent, their existence 
should be suspected and sought for in every case in 
which there is apparent weakness of the external recti 
muscles. 

The connection between hypermetropia and eso- 
phoria is the same as that between hypermetropia and 
convergent squint. In hypermetropia, as has been 
explained, the normal parallelism between the effort of 
accommodation and the effort of convergence is de- 
stroyed — accommodation is always in excess of con- 
vergence. Under such circumstances there is an ever- 
present tendency to restore the parallelism between these 
two functions. Convergent squint results when this 
tendency is more powerful than the desire to maintain 
binocular vision; esophoria, when it is less powerful, 
when the desire for binocular vision prevails. The 
abandonment of the effort to maintain binocular vision 
means, usually, the disappearance of the previously 
experienced asthenopia; the maintenance of binocular 
vision, with the attendant esophoria, means its persist- 
ence. The complete disappearance of the esophoria, 
as a result of the correction of the refractive error, proves 
that the external recti muscles were only seemingly at 
fault; its incomplete disappearance shows an actual in- 
sufficiency of these muscles. The existence of a con- 
siderable amount of hypermetropia, without esophoria, 
indicates one of three things — exceptionally energetic 
accommodative power, unusually strong external recti 
muscles, or actual insufficiency of the internal recti. 

It must not be supposed, however, that esophoria is 



474 PREVALENT DISEASES OF THE EYE. 

always dependent upon hypermetropia. On the con- 
trary, marked examples of this fault are met with in 
emmetropes and in individuals who are but slightly 
hypermetropic, and other cases are encountered in 
which the full correction of the hypermetropia elimi- 
nates but a fraction of the muscle-fault. These are the 
cases in which there is actual insufficiency of the external 
recti muscles. Whether, under such circumstances, 
these muscles are imperfectly developed, or are attached 
to the eyeball in such fashion as to lessen their efficiency, 
or whether they are only relatively weak as compared 
with their opponents, the internal recti, or whether, 
finally, the fault is in their nervous supply, it is seldom 
possible to determine; but there can be little doubt that 
every case of real insufficiency of the external recti 
muscles finds its explanation in the existence of one, 
or, it may be, more than one, of these conditions. 

The existence of esophoria and its degree are to be 
determined by the same tests that have been mentioned 
as best adapted to the measurement of exophoria, and 
here, too, the muscle-balance for near vision should be 
ascertained with as much care as for distance. It goes 
without saying that in every case of esophoria a careful 
test of the refraction should be made, and the effect upon 
the muscle-balance of the correction of any refractive 
anomaly that may be found noted; for only in this way 
can we know whether we are dealing with an actual, 
or merely an apparent, muscular fault. 

Treatment. — From what has just been said, it is evi- 
dent that the first step in the treatment of esophoria 
consists in the determination of the refractive condition 
of the eyes, and to this end a cycloplegic is usually neces- 
sary. If hypermetropia or astigmatism is discovered, 
this must be corrected, and the influence which this 



MUSCULAR ANOMALIES OF THE EYES. 475 

correction exerts upon the muscle-balance ascertained, 
the muscle-tests being made not only while the eyes are 
under the influence of the cycloplegic, but after they 
have recovered fully from its effect. If a marked error of 
refraction is found to be present — a hypermetropia, let 
us say, of 2 D. or 3 D., and especially if this is compli- 
cated by astigmatism — it is commonly best to be satis- 
fied, for the time being, with a fairly full correction of 
this defect, even though this may leave a considerable 
residuum of esophoria; for, with the disappearance of 
the asthenopia and the tension of accommodation, it is 
not unusual to find a decided improvement in the mus- 
cle-balance. If, however, in spite of such correction, 
the asthenopia persists, and the residual esophoria does 
not diminish, one of two things must be done — either 
prisms must be combined with the previously prescribed 
lenses, or a tenotomy must be performed. 

No hard and fast rule can be laid down as to when one 
and when the other of these measures should be resorted 
to; but, in general, it may be said that when more than 
6° of esophoria in distant vision, and its equivalent, 2° 
or 3 , in near vision, remain after the correction of the 
refractive error, or when the asthenopic symptoms per- 
sist notwithstanding the correction of 4 of esophoria 
by prisms, a tenotomy is indicated. This same rule as 
to the choice between prisms or a tenotomy, it may be 
added, holds good when no, or only a trivial, error of 
refraction exists. 

It should be borne in mind, however, that the ocular 
muscle-balance is often markedly influenced by the 
general condition of the individual, and that a pro- 
nounced change for the better in this respect may 
follow temporary rest of the eyes, and a building up of 
the system by suitable tonics. One should hesitate, 



4j6 PREVALENT DISEASES OF THE EYE. 

therefore, to resort to operation if there are reasonable 
grounds for supposing that the symptoms are but the 
expression of a run-down state of the system, of a gen- 
eral lack of muscular tone. When, as not infrequently 
happens, the muscle-balance is at fault in distant vision 
only, or, it may be, in near vision onlv, a tenotomy is 
contraindicated, since it must necessarily do as much 
harm as good, substituting for one sort of heterophoria 
another sort, quite as apt to give rise to annoying symp- 
toms. 

As to the advisability of operating at all for latent 
muscular anomalies there is still, as has already been 
mentioned, considerable diversity of opinion. My own 
convictions upon this point are very definite. Con- 
servatism is to be commended, and an operation is not 
to be thought of until the influence of the refraction 
upon the muscle-balance has been carefully studied. 
When, however, this source of error has been eliminated, 
and there are clear indications, as I view them, for a 
tenotomy, I operate with the fullest confidence that 
marked benefit will result. When, some vears ago, I 
first began to tenotomize non-squinting eves, I confess 
I did so with some trepidation; but abundant experience 
has convinced me that few surgical procedures yield 
more gratifying results than a clearly indicated tenotomy 
for the relief of muscular asthenopia. 

Perhaps, I should make it plain that bv "tenotomy" 
I mean a real division of the tendon. There is, in mv 
opinion, no room for the so-called graduated or partial 
tenotomies. If the muscle-fault is so trivial that it can 
be relieved by such a procedure, it is too trivial to re- 
quire operation at all; it can be more satisfactorily dealt 
with by means of glasses. On the other hand, if it is 
sufficiently pronounced to demand operation, it will 



MUSCULAR ANOMALIES OF THE EYES. 477 

certainly not be relieved by a procedure which is little 
better than a pretence. A "guarded tenotomy, " that 
is to say, one in which the tendon is completely divided, 
but the section is not extended to Tenon's capsule, is 
frequently indicated; but an operation which accom- 
plishes less than this had better be left undone. 

It has been a matter of surprise to me how much 
tendon-cutting is not only permissible, but is demanded, 
in certain cases of lateral heterophoria. Not very 
infrequently in marked esophoria a free tenotomy 
of both internal recti muscles, and in pronounced exo- 
phoria an equally free division of both external recti 
muscles, will hardly suffice to restore a normal muscle- 
balance, although a squint has never manifested itself. 
It is noteworthy that an actual squint is often corrected 
by less free tenotomizing than is sometimes demanded 
in these latent muscular faults. 

Hyperphoria. — This condition, in which there is a 
suppressed inclination to vertical squint, is one of the 
most annoying of the latent muscular faults. From 
exophoria and esophoria it differs essentially in that it 
is but little influenced by the refractive condition of the 
eyes — anisometropia, in which the eyes are of unequal 
focus, being the only ametropic condition which seems 
to promote its development. More constantly, there- 
fore, than the lateral forms of heterophoria it is dis- 
tinctly a muscular fault. Not infrequently, it would 
seem, it is the result of an incompletely-recovered-from 
paralysis of one of the muscles which have to do with 
the vertical movements of the eyes. In other cases it is 
due to some congenital or acquired insufficiency of one 
of these same muscles. 

Hyperphoria is capable of producing any and all of 
the distressing symptoms, local and remote, which have 



47$ PREVALENT DISEASES OF THE EYE. 

been described as arising from eye-strain, and, although 
it is not a common defect, it should be looked for in 
every case of asthenopia. Exceptionally it is present 
only in near, or it may be only in distant, vision; it 
should be sought for, therefore, in both. The best test 
which has been devised for its detection and measure- 
ment is the multiple rod of Maddox, supplemented in 
the tests for near vision, as has already been mentioned, 
by the pin-hole light of Schild. 

Treatment.— Hyperphoria, may be corrected by 
prisms or by operation. If the defect is pronounced, 
a guarded tenotomy should be performed. If it is not 
pronounced, it is much better to correct it by means of 
prisms. Experience has taught me that it is more 
difficult to predicate the effect of a tenotomy upon a 
superior or an inferior rectus muscle than of one upon 
either of the lateral recti. I am, therefore, little dis- 
posed to operate, as some surgeons do, for the correction 
of the lower degrees of vertical heterophoria. Such 
cases, that is to say, cases in which there are not more 
than 3 or 4 of hyperphoria, can almost always be 
dealt with satisfactorily by means of vertical prisms, 
either alone or in combination with such other correc- 
tion as may be demanded. And even in the higher 
grades the tenotomy should be distinctly "guarded"; 
for it is better to accomplish too little — and later, per- 
haps, operate upon the other eye — than to do too much. 

In operations upon the lateral muscles glasses usually 
afford us much assistance, and, besides, these muscles 
are more fully under the control of the will, so that a 
slight over-correction or under-correction is not a matter 
of moment, since the eyes come to our assistance, so to 
speak, and help us greatly in securing the result desired. 
In operations upon the vertical muscles this is not the 



MUSCULAR ANOMALIES OF THE EYES. 479 

case, and a slight over-correction will sometimes give 
quite as much discomfort as the original defect. 

Again, it is not always possible to secure a result 
which is equally satisfactory in both far and near vision. 
If the superior rectus of the upward-tending eye be 
divided, just the effect desired in near vision may be 
obtained, but when the eyes are directed to distant 
objects there may be trouble. On the other hand, if 
the inferior rectus of the opposite eye be severed, all 
may be well in distant vision, but not in near vision. In 
a word, more caution is requisite, and less assurance as 
to the outcome can be felt, in operating for the correc- 
tion of vertical, than for the correction of lateral, 
heterophoria.* At the same time, there are, unquestion- 
ably, cases in which an operation is clearly demanded, 
and in which relief can be obtained in no other way. 

* In a paper, "Are tenotomies for hyperphoria necessarily more 
uncertain in their results than those for esophoria and exophoria," 
published in the "Trans, of the American Ophthalmological Society" 
for 1903, and in the "Maryland Medical Journal," Jan., 1904, the 
author's views upon this point have been more fully set forth, and 
illustrative cases reported. 



CHAPTER XIII. 

INJURIES OF THE EYE AND ITS APPENDAGES. 

Injuries of the eyelids, of moment, are not of 
common occurrence, and, therefore, the subject does 
not demand extended consideration. A chief aim in 
dealing with traumatic lesions of the lids is to prevent 
subsequent deformity, especially malposition of the 




Fig. 172. — Great deformity of the lid from a knife wound — the deformity 
being in large measure due to lack of early surgical attention (Lawson). 

lid-margins and of the lacrimal puncta, since this is 
not only attended by considerable facial disfigurement, 
but is apt to give rise to troublesome epiphora (Fig. 172). 
The occurrence of ankyloblepharon (adhesion of the 
lid-margins) (Fig. 173) and of symblepharon (adhesion 
of the lid to the eyeball) is also to be carefully guarded 
against. As the tissues of the lids are very vascular, 

480 



INJURIES OF THE EYE AND APPENDAGES. 481 

sloughing is not apt to occur, and stitches may be used 
freely to secure accurate apposition. 





Fig. 173. — Symblepharon and anchyloblepharon following burn by molten 
iron (Haab). 







Fig. 174. — Symblepharon following lime burn (Hansell and Sweet). 




Burns of the external surface of the lids are often 
difficult to deal with, and, if severe, are prone to produce 
ectropion. Burns of their conjunctival surface from 

3 1 



482 PREVALENT DISEASES OF THE EYE. 

caustic agents, molten metal, etc., tend to the produc- 
tion of entropion and symblepharon (Fig. 174). 

Treatment. — Incised wounds of the lids (Fig. 175), 
after having been thoroughly cleansed with a 1 : 5000 
sublimate solution, should be neatly closed by a liberal 
use of stitches (fine black silk), and dressed with silver- 
foil and collodion. Lacerated wounds commonly do 
better with a wet dressing — a gauze pad, wet with a sat- 
urated solution of boracic acid, and kept in place with a 
light bandage. The presence of any foreign substance in 
the wound should be carefully searched for. Loss of a 
considerable part of the external integument of the lid 




Fig. 175. — Incised wound of the palpebral margin (Lawson). 

must be replaced by skin grafts, the thin grafts of 
Thiersch being best adapted for this purpose. Slitting 
of the canaliculus, the lower one especially, is at times 
indicated for the relief of epiphora consequent upon 
wounds of the lids. 

Burns of the external surface of the lids should be 
anointed with borated vaselin, to which cocain may be 
added, or they may be covered with absorbent gauze 
wet with a solution of sodium bicarbonate. Carbolized 
oil and lime-water is also a useful application. In 
burns of the palpebral or bulbar conjunctiva a solution 
of atropin (alkaloid) in castor-oil (gr. iv-5j) is useful. 



INJURIES OF THE EYE AND APPENDAGES. 483 

Gunpowder burns are especially annoying from the 
disfigurement which they cause. Efforts to remove 
mechanically the disintegrated powder-grains are usu- 
ally unsuccessful. If, however, these efforts are sup- 
plemented by the application of hydrogen peroxid to 
the stained tissue better results are obtained. The 
application is conveniently made by means of a sharp 
toothpick, armed with a little absorbent cotton. 

Destruction of the external integument of the lids 
resulting from burns may call for Thiersch grafts, which 
are best applied after the burned surface has become 
covered with granulations. When the burn has in- 
volved the lid-margins or the palpebral and bulbar 
conjunctiva, the occurrence of ankyloblepharon and 
symblepharon should be guarded against by repeated 
separation of the opposed raw surfaces and the liberal 
application of vaselin. 

Injuries of the Bulbar Conjunctiva. — Considerable 
wounds of the bulbar conjunctiva, without involvement 
of the deeper tunics of the eye, are rare. Occasionally, 
however, the conjunctiva may be so lacerated as to re- 
quire the careful insertion of stitches, a procedure 
fraught with little or no risk. 

Severe burns of the conjunctiva, from "concentrated 
lye," lime, strong acids, and molten metal (Fig. 1 76), are 
more common, and, as they often involve the cornea, 
and are apt, as has been pointed out, to cause symble- 
pharon, they are of serious concern. 

Treatment. — In burns of the conjunctiva, if the fornix 
has escaped injury, it is usually possible, through the 
measures described in treating of injuries of the lids, to 
prevent the occurrence of symblepharon; but when this, 
as well as the tarsal and bulbar conjunctiva, is involved, 
our efforts in this direction are almost sure to prove un- 
availing. 



4 8 4 



PREVALENT DISEASES OF THE EYE. 



When the burn has been caused by a caustic sub- 
stance, such as lye, lime, or a strong acid, and the case 
is seen promptly, the eye should be bathed freely with a 
chemically neutralizing agent, such as diluted vinegar, 
if the burn has been produced by lime or lye, or a solu- 
tion of sodium bicarbonate, if it is the result of an acid. 
Any remnants of the caustic substance should, of course, 
be carefully removed. The subsequent treatment con- 







Fig. 176. — Recent burn of the palpebral and ocular conjunctiva by a 
piece of hot iron (Haab). 

sists in douching the eye with a fifteen-grain solution of 
boracic acid, in the instillation of a four-grain solution 
of atropin (alkaloid) in castor-oil, and in efforts to pre- 
vent, as has been explained, the formation of adhesions 
between the lids and the eyeball. 

In incised or lacerated wounds of the conjunctiva, 
after the parts, if they are not disposed to fall together, 



INJURIES OF THE EYE AND APPENDAGES. 485 

have been united by stitches, a collyrium of boracic acid 
should be prescribed, and, if there is much discomfort 
and tumefaction, a lotion of opium and boracic acid, 
to be applied over the lids on absorbent gauze. 

Superficial Injuries of the Cornea. — Burns of the 
cornea are of serious concern because, when at all severe, 
they are apt to leave a persistent opacity, which, if cen- 
tral, will greatly impair vision (Fig. 177). One of the 
most unfortunate cases of this kind that I have en- 
countered resulted from dropping aqua ammoniae into 
the eye in mistake for a collyrium. A severe and 
obstinate keratitis followed, and an opacity was left 
which markedly and permanently impaired the sight. 




sysw-^ 



Fig. 177. — Leucoma resulting from a lime burn (Lawson). 



Non-penetrating wounds of the cornea are seldom 
attended by untoward results, unless they happen to be- 
come infected, or involve the visual zone and give rise 
to persistent opacity. Abrasions, which simply dis- 
turb the corneal epithelium, though they may cause 
acute suffering for a short time, soon heal, as the epi- 
thelium is quickly regenerated. 

Treatment. — If there is not much discomfort, and the 
wound is not infected, no other treatment than the in- 
stillation of a ten-grain solution of boracic acid is called 
for. If there is considerable irritation, photophoria, 
and lacrimation, atropin (one to four grains to the 



486 PREVALENT DISEASES OF THE EYE. 

ounce) should be added to the boracic acid solution. 
A one- to two-grain solution of the local anesthetic 
holocain hydrochlorate is also a useful application, as it 
affords prompt relief from pain, is measurably antisep- 
tic, and does not disturb the corneal epithelium and 
thereby favor infection, as does cocain, which is much 
oftener employed in like circumstances. 

If it is evident from the presence of pus in the wound 
and in the neighboring corneal tissue that infection has 
occurred, the wound should be cleaned, and carefully 
cauterized with pure carbolic acid. The cleaning and 
the application of the acid can be done effectually and 
conveniently by means of a sharp, wooden toothpick, 
about the tip of which a very little absorbent cotton has 
been tightly wound. The acid should be used in 
minute quantity, and should not be permitted to come 
in contact with the uninjured corneal surface. After- 
ward the eye should be flushed with a boracic acid or 
normal salt solution. Further treatment should consist 
in dropping freely into the eye, as often as once in three 
hours, freshly prepared, undiluted chlorin water, which 
is one of the most efficient, and at the same time one of 
the best borne, ocular antiseptics. In addition, atropin 
or holocain should be prescribed, and, if there is much 
pain, an opium lotion. Should the wound after twenty- 
four hours still present an unhealthy appearance, it 
should be cleaned, and the carbolic acid again applied. 
In burns of the cornea the solution of atropin in castor- 
oil, already mentioned, is an excellent application. 

The Superficial Lodgment of Foreign Bodies 
in the Eye. — This is one of the commonest accidents 
to which the eye is subject, and, though seldom followed 
by serious consequences, it often gives rise to much 
suffering, which can be immediately relieved by the 



INJURIES OF THE EYE AND APPENDAGES. 487 

exercise of a little dexterity upon the part of the physi- 
cian whose help may be sought. On the other hand, 
the display of a considerable measure of sinisterity on 
his part (if the word is permissible) is not apt to be soon 
forgotten by the unfortunate patient. 

Mechanics, particularly those engaged in metal- 
grinding and polishing, stone-cutting, and similar occu- 
pations, are especially subject to this accident, and so 
are persons who are much exposed to wind and dust and 
to flying cinders. 

Almost without exception, foreign bodies which do 
not penetrate the globe find lodgment — if they find it at 
all, for many are washed out by the tears or removed by 
the individual's own efforts — in 
one of two places: either they 
attach themselves to the cornea, 
or they adhere to the inner sur- 

face of the upper lid, that is to J ig " ^--Foreign body 
11 m adherent to inner surface 

say, to the tarsal conjunctiva of upper lid. Lid everted 
(Fig. 178), for they rarely find to show a usual P oint 

, . . . . of lodgment (Jackson). 

their way into the superior retro- 

tarsal fold. In the exceptional instances in which a 
foreign body adheres to the bulbar conjunctiva, it will 
be found that it has hit the eye with considerable force, 
or was hot at the moment of impact, and has partly 
or completely penetrated this membrane. 

The cornea is the usual place of lodgment for foreign 
bodies which are driven, so to speak, into the eye, and 
for this reason it is there they are commonly discovered 
in the case of metal-grinders, stone-cutters, etc. In- 
deed, it is not unusual to find the cornea? of persons 
engaged in such occupations studded over with innu- 
merable little nebulous opacities, each marking the 
point of impact of a bit of steel or stone, or a particle of 




488 PREVALENT DISEASES OF THE EYE. 

emery. Cinders, and such like substances, which sim- 
ply "fly into the eye," have no such definite predilec- 
tions, and attach themselves as often to the superior 
tarsal conjunctiva as to the cornea. 

The canaliculus is one of the unusual places in which 
foreign bodies are found, and yet they sometimes lodge 
there, especially detached eyelashes, which commonly 
enter but for part of their length, the projecting portion 
causing much discomfort by coming in contact with 
the sensitive bulbar conjunctiva. 

There is a class of foreign bodies, met with from 
time to time, that seem to deserve especial mention, 
because their true character is apt to be overlooked by 
the inexperienced, and because, when once they have 

attached themselves to the eye, 
J0L %W they have a habit of remaining 

attached for an almost interm- 
inable period. I have preserved 
quite an interesting collection of 
Fig. 1 79. — " Chaff -particle" these intractable little intruders, 

attached to the corneal limbus whkh CQnsist of a rtion of the 
(Haab). r 

outer shell of some tiny seed — 
weed or grass seed (Fig. 179). They have several 
peculiarities, which explain their unusual behavior: 
They are concavo-convex in shape, they are semi- 
transparent, and they are capable of resisting for a 
very long time the solvent action of the secretions of 
the eye. Their shape makes them adhere firmly to 
the eye, — they are almost always found upon the 
cornea, — their indestructibility renders them very 
nearly everlasting, and their transparency causes 
their true character to be easily overlooked. In my 
collection there is one of these shells which remained 
attached to the cornea for twelve months, and there are 




INJURIES OF THE EYE AND APPENDAGES. 489 

several which maintained their hold for from two to five 
months; and I may add, in support of what I have 
said as to the possibility of a mistaken diagnosis being 
made in these cases, that one of my earlier patients, with 
this sort of foreign body, narrowly escaped an energetic 
course of mercury at the hands of his family physician. 

The suffering caused by the presence of a foreign 
body in the eye varies greatly in different individuals; 
but usually it is severe, and most intense when the body 
is sharp or rough, and is attached to the tarsal con- 
junctiva in such a position as to cause it, from the move- 
ments of the eye and lids, to scrape the surface of the 
cornea. Under such circumstances the upper part of 
the cornea is sometimes found extensively denuded of 
its epithelium. 

In reaching a diagnosis as to the presence of a foreign 
bodv in the eye, it is well to bear in mind, in the first 
place, that a foreign body frequently enters the eye with- 
out the knowledge of the individual or any suspicion on 
his part that such an accident has occurred, and, in the 
next place, that patients often insist that a foreign body 
is present, when such is not the case. Whatever the 
patient's convictions, it is always best, in every case in 
which the symptoms even remotely suggest the pro- 
priety of so doing, to search carefully for the possible 
presence of some irritating foreign substance. The 
cornea should first be inspected, — and here "oblique 
illumination " (see page 19) will often prove of in- 
valuable assistance — and then the upper lid should be 
everted, as described on page 22, and the tarsal con- 
junctiva carefully scanned. If a foreign body is not 
found in either of these places, and is not, as may pos- 
sibly happen, lying loose upon the bulbar conjunctiva 
or in the lower retrotarsal fold, it may safely be con- 
cluded that none is present. 



49° PREVALENT DISEASES OF THE EYE. 

Treatment. — In general, whether a foreign body be 
lodged upon the cornea or beneath the upper lid, it can 
be most easily removed — simply wiped from its point 
of attachment— by the help of a sharp, wooden tooth- 
pick, having a little absorbent cotton wrapped, mop- 
like, over its point (Fig. 180). This will not suffice, 
however, if the foreign body has been driven forcibly 



Fig. 180. — Toothpick armed with cotton for removal of foreign bodies. 

into the eye, and is embedded in the corneal tissue. 
Under such circumstances an old-fashioned couching 
needle, or a similar needle such as is made now- 
adays expressly for this purpose (Fig. 181), should be 
employed, as the foreign body must be picked out of 
its bed. To prevent possible infection the needle 
should, of course, be previously sterilized by immersion 
in boiling water. 

In removing a foreign body from 
the cornea it is always best to employ 
cocain, which tends to loosen its hold, 
besides rendering the operation pain- 
less and, therefore, much easier of 

Fig. 181. — Needle r . 

for removal of foreign performance. 1 his is not necessary, 
bodies embedded in however, when the body is attached 
to the inner surface of the lid, as then 
its removal is a painless procedure. 

After the removal of a scale of iron or steel, or a bit 
of emery, from the cornea it often happens that a brown- 
ish stain is left, which conveys the impression that the 
removal has not been complete. Further efforts, at the 
moment, to detach this are apt to prove abortive, and 
considerable traumatism may result if these efforts are 



PLATE X. 




rupture of the sclera, with hemorrhage into the anterior 
Chamber (after Sichel). 



INJURIES OF THE EYE AND APPENDAGES. 49I 

persisted in. It is better to wait for twenty-four or 
forty-eight hours, when it will be found that the seeming 
remnant of the foreign body, which is, in fact, only 
stained cornea tissue, has become loosened, and can be 
easily removed. 

If keratitis has resulted from the irritation produced 
by a foreign body, or if infection of the wound has oc- 
curred, the measures prescribed for the treatment of 
simple or infected wounds of the cornea, as may be indi- 
cated, should be promptly employed. 

The extraction of a foreign body which is deeply 
embedded in the cornea, and which may easily be dis- 
placed into the anterior chamber, is a delicate proce- 
dure, which had best be left to expert hands. 

Contusions of the eye are of common occurrence, 
but fortunately, owing to the protection afforded by the 
bony orbital margin and the elastic cushion of fat which 
occupies the depth of the orbit and permits of consider- 
able recession of the eyeball, serious injury seldom re- 
sults, only, indeed, when the blow is exceptionally severe 
or is of unusual character. But for these provisions 
of nature, many eyes only "blacked" by blows would, 
doubtless, be irreparably damaged. 

Blows from objects of such shape or size as not to be 
arrested by the orbital margin are the ones which are 
apt to be disastrous. Rupture of the eyeball (see 
Plate X), dislocation of the lens, laceration of the 
iris (Fig. 182), iridodialysis (Fig. 183), detachment or 
other injury of the retina and choroid coat, and exten- 
sive intraocular hemorrhage, are among the conse- 
quences of such injuries. On the other hand, even 
severe blows from larger objects, such as the fist, are 
seldom followed by anything more serious than swelling 
and ecchymosis of the lids and extravasation of blood 



492 



PREVALENT DISEASES OF THE EYE. 



beneath the conjunctiva and into the loose cellular 
tissue of the orbit. When we consider the delicate 
structure of the eye it is indeed surprising to what rough 
usage it may be subjected without serious injury. 
However, it is only sound eyes that exhibit such im- 
munity. Myopic eyes, as has been stated already, are 




Fig. 182. — Radiating and pupillary rupture of the iris (Hansell and Sweet). 




Fig. 183. — Iridodialysis caused by the explosion of a firecracker (Lawson), 

especially liable to be seriously damaged by compara- 
tively trivial traumatisms, and so are those which have 
suffered from previous attacks of iritis, choroiditis, etc. 
Opacity of the lens, traumatic cataract, is one of the 
not uncommon results of severe contusions of the eye. 
And this may happen without rupture of the lens cap- 



INJURIES OF THE EYE AND APPENDAGES. 493 

sule, simply from the concussion to which the eye is 
subjected. Mydriasis and loss of the power of accom- 
modation from paralysis of the sphincter pupillae and 
the ciliarv muscle, usually transient, also occur. Hem- 
orrhage into the anterior chamber, and marked ex- 
ophthalmos from extravasation of blood into the cellular 
tissue of the orbit, are observed, and rarely such injury 
of the muscles or motor nerves of the eye as may lead 
to the production of squint. Injun' of the lacrimal sac 
and nasal duct from blows is not unusual, and may 
result in occlusion of the duct and persistent and annoy- 
ing epiphora. 

Among the commoner causes of severe contusions of 
the eve may be mentioned blows from flying chips in 
chopping and splitting wood, from stones thrown by 
accident or design, from pebbles or bullets shot from 
air-guns, from nails awkwardly struck, from limbs of 
trees, and from corks driven with violence from cham- 
pagne or soda-water bottles. In one instance I saw an 
eve that was irreparably damaged from having been 
struck by a "ball" from a Roman candle, which had 
been foolishly aimed at a party of boys. 

Treatment. — This will depend, of course, upon the 
nature of the injury, which may be so severe as to de- 
mand immediate enucleation of the damaged eye, or 
so trivial as to call only for the application of ice-cloths 
and a few days' rest from work. The lotion of opium 
and boracic acid is a most useful application, and atro- 
pin is often indicated, especially when the iris is injured. 
Sodium salicylate, in liberal doses, has a marked influence 
in controlling supervening inflammation, particularly 
of the deeper structures of the eye. 

In severe contusions of the eye the danger of sympa- 
thetic ophthalmitis should not be lost sight of, the cases 



494 PREVALENT DISEASES OF THE EYE. 

in which this is most to be feared being those in which 
rupture of the tunics has occurred, with subsequent 
partial atrophy of the ball. Enucleation of the injured 
eye is indicated under such circumstances, and should 
not be unnecessarily deferred. 

Penetrating wounds of the eye are always of 
serious concern, not only because of the immediate dam- 
age involved and the inflammation liable to supervene, 
but because of the danger of infection of the wound, 
which, once established, is very apt to end in destructive 
panophthalmitis. 

Penetrating wounds of the cornea often involve the 
iris and not infrequently the lens, and when this is the 
case prolapse of the iris and traumatic cataract usually 
result. Wounding of the lens constitutes a grave com- 
plication, not only because of the ultimate effect upon 
vision, but because the swelling of the lens, which usually 
quickly supervenes, adds materially to the risk of serious 
inflammation of the iris and ciliary body. It may 
also give rise to a glaucomatous condition of the eye, 
resulting, if not soon controlled, in permanent damage 
to the optic nerve and retina. Incised wounds of the 
cornea which do not involve the iris or lens usually do 
well, though they not infrequently give rise to displace- 
ment of the pupil and to the formation of an anterior 
synechia. If central, they are apt to impair vision 
markedly, because of the resulting opacity and disturb- 
ance of the corneal curvature. 

Wounds of the sclera and ciliary body are of grave 
import, and are often complicated by hernia of the 
ciliary body or iris (Fig. 184) and prolapse of the 
vitreous humor. Infection is especially apt to occur 
under such circumstances, since the vitreous humor 
furnishes an admirable culture medium for the growth 
of pyogenic bacteria. 



INJURIES OF THE EYE AND APPENDAGES. 495 

Penetrating wounds of the sclera, back of the ciliary 
region, though they usually involve the choroid and 
retina, are commonly not so serious in their conse- 
quences as are those of the ciliary body. If, however, 
infection occurs they result disastrously, and, even 
without this happening, if they are extensive and lac- 
erated, they usually lead to loss of sight and ultimately 
to atrophy of the eyeball (Fig. 185). 

Treatment. — In view of the attendant dangers, and 
the serious complications liable to occur, the treatment 
of penetrating wounds of the eye should be consigned, if 




Fig. 184. — Rupture of the sclera with incarceration of the iris from a blow 

(Lawson). 

practicable, to the hands of the specialist. For, in the 
first place, the question whether it is worth while to 
attempt to save the eye, whether immediate enucleation 
is advisable or not, often presents itself. Then, if there 
is a prospect of saving the eye, careful antiseptic pre- 
cautions are called for, and, very probably, the abscis- 
sion or replacement of prolapsed portions of the iris or 
ciliary body, or possibly the extraction of a wounded or 
dislocated lens. 

As a "first aid" in such cases, the lids and the eye 
itself should be gently bathed with a 1 : 8000 sublimate 



49 6 



PREVALENT DISEASES OF THE EYE. 



solution, and a gauze pad, wet with the same solution 
or a sterilized lotion of opium and boracic acid, should 
be applied over the closed lids, and kept in place by a 




Fig. 185. — A trophy of the eyeball, the result of severe iridocyclitis caused 
by a penetrating wound (Fuchs, in part after Wedl-Bock). The umbrella- 
like (the usual form of) detachment of the retina is well shown. The 
eve is smaller and of irregular shape, chiefly from the wrinkling of the 
sclera, S, behind the points of attachment of the ocular muscles, the 
rectus internus, ri, and the rectus externus, re. The cornea, C, is 
diminished in size, flattened, and wrinkled especially on its posterior 
surface. At its inner border it bears the depressed cicatrix, A T , which was 
produced by the injur}'. The anterior chamber is shallow; the iris, i, is 
thickened and forms an unbroken surface, because the pupil is closed by 
exudate. Behind the iris lies the shrunken lens, /, and behind this is the 
great hull of cyclitic membrane, c, the shrinking of which is the cause of 
the atrophy of the eyeball. By reason of this shrinking, the ciliary pro- 
cesses, the pigment layer of which has markedly proliferated, are drawn 
in toward the center, and, together with the adjacent choroid, ch, are 
detached from the sclera; between the two structures are seen the dis- 
joined lamellae of the suprachoroid membrane, a. The retina, r, is de- 
tached and folded in the form of a funnel, which incloses the remains of 
the degenerated vitreous, g. The subretinal space, s, is filled with a fluid 
rich in albumin. The optic nerve, 0, is thinner than usual and atrophic. 

light bandage. And here, if practicable, as I have said, 
the general practitioner's care of the case should cease. 



INJURIES OF THE EYE AND APPENDAGES. 497 

It, in spite of antiseptic precautions, definite signs of 
infection of the eye exhibit themselves, enucleation is 
commonly indicated, and, if promptly performed, will 
save much unnecessary suffering. As has already been 
pointed out, the danger of cerebral or general infection 
is not appreciably greater from operating under such 
circumstances than from permitting the panophthal- 
mitis to run its tedious course. There is also the risk of 
sympathetic ophthalmitis from extensive wounds of the 
cornea and iris, or of the sclera and ciliary body, and 
this is another reason why, if there is no prospect of 
useful vision being preserved, enucleation should be 
resorted to without unnecessary delay. 

Wounds of the Eye Complicated by the Lodgment 
of Foreign Bodies within the Ball. — The dangers 
attendant upon penetrating wounds of the eye are 
greatly increased by the lodgment of a foreign body 
within the ball. In the first place, the risk of infection 
is much greater (see Fig. 130), and, even if this does 
not occur, the irritation caused by the continued pres- 
ence of the foreign body is almost certain to set up an 
insidious inflammation of the deeper structures of the 
eye, which ends in loss of sight. Again, there is greater 
probability of sympathetic ophthalmitis supervening. 
Indeed, this dreaded complication is more often due to 
the presence of a foreign body in the primarily affected 
eye than to any other cause. 

Much depends, it is true, upon the nature of the 
foreign body, and upon its position within the ball. 
Foreign bodies which, though sterile, undergo chemical 
changes, such as bits of iron or steel or copper, are most 
apt to give rise to disastrous consequences. On the 
other hand, spicules of glass or small fragments of stone 
are not so surely destructive of sight, since they may 

3 2 



49$ PREVALENT DISEASES OF THE EYE. 

become encysted, and in this way be rendered innoc- 
uous. A striking case of this character has come under 
my observation, in which a small piece of glass, after 
entering the anterior chamber, fell through the pupil, 
and lodged in the ciliary processes. Sharp inflamma- 
tory reaction followed, but soon subsided, and evidently 
resulted in the glass becoming encysted; and to this day, 
the accident having occurred more than thirty years ago, 
no ill effects have been experienced, the injured eye 
being as free from irritation, and as capable of perform- 
ing its daily task, as its fellow. 

As to the influence of location, a foreign body lodged 
within the lens capsule, although almost sure to cause 
the development of cataract, may not provoke inflam- 
matory complications, and this, in less measure, is true 
of one suspended in the vitreous humor. As opposed 
to this, a foreign body embedded in the iris, ciliary 
body, or choroid is more certain to excite destructive 
inflammation, and is also more apt to cause sympathetic 
implication of the fellow-eye. Wounds of the eye from 
bird-shot are especially dangerous, partly from the 
character of the wound, and partly from the nature of 
the foreign body. 

In order to penetrate the tunics of the eye a foreign 
body must have considerable weight relatively to its 
size, and must be driven with great force. This is 
especially true of those that impinge upon the very 
tough sclera, which is less frequently penetrated than 
the cornea. Foreign bodies which pass through the 
sclera commonly fall into the vitreous chamber, and 
in time come to rest upon the retina, at the bottom of the 
eyeball. Those which enter through the cornea excep- 
tionally fall into the anterior chamber, but more often 
lodge in the iris or pass through it into the vitreous 



INJURIES OF THE EYE AND APPENDAGES. 499 

body, frequently wounding the lens in their course, and 
giving rise to a traumatic cataract (Fig. 186). Those 
which lie loose in the anterior chamber usually excite 
iritis, and eventually become encysted in the narrow 
space between the lower margin of the iris and the 
cornea. 

Treatment. — Before the days of the electro-magnet 
and skiagraphy, the lodgment of a foreign body within 
the eyeball usually meant loss of sight and, sooner or 
later, enucleation of the eye. Nowadays, many such 
eves are saved, and often with useful vision. By means 




Fig. 186. — Spicule of iron in the vitreous (extracted); laceration of the 
iris, traumatic cataract, and turbidity of the vitreous (Haab). 

of skiagraphy the exact location of nearly all foreign 
bodies can be determined, and this, it is evident, greatly 
facilitates their removal (Figs. 187,188,189). By the 
help of the magnet bits of iron and steel (and they 
constitute a very large proportion of the foreign bodies 
which enter the eye), in most instances, can be extracted, 
and, not infrequently, so as to leave a serviceable eye. 
For this purpose the powerful electro-magnet of Sweet 
is the instrument I have found most effective 
(Fig. 190). 



500 



PREVALENT DISEASES OF THE EYE. 



By means of oblique illumination foreign bodies lying 
in the anterior chamber or superficially in the lens, or 
that are partially embedded in the iris, can usually 
be detected without difficulty, unless, as sometimes hap- 
pens, they are hidden by hemorrhage; but only excep- 
tionally can those that have passed into the vitreous 
chamber be discovered, for in most instances the media 




Fig. 187. — Sweet's apparatus for localizing foreign bodies in the eye with the 

Rontgen rays. 



are too cloudy to permit of a satisfactory ophthalmo- 
scopic examination. And it is here that skiagraphy 
proves invaluable. When this test is not available the 
"pain reaction" test may be employed, provided the 
foreign body is magnetic. This consists in approach- 
ing a strong magnet very close to the eye, or bringing it 



INJURIES OF THE EYE AND APPENDAGES. 5OI 

in actual contact with it. The pull which it exerts 
upon fragments of iron or steel, especially if they are 
of considerable size, usually causes decided pain. 
A negative result does not definitely exclude the pres- 
ence of a magnetizable foreign body, but, at least, it 
renders it improbable. 

In every case in which there is reason to fear that a 
foreign bodv has entered the eye the tests described — 




Fig. 188. — Radiograph showing foreign body (Sweet). 



especially the skiagraphic test — should be employed 
with as little loss of time as possible; for the sooner it is 
discovered and removed the greater, other things being 
equal, is the likelihood of saving the eye. In the mean- 
time, until the case can be placed in the hands of a 
specialist, antiseptic measures, such as have been men- 
tioned in connection with the treatment of penetrating 
wounds of the eye, should be employed, a sterilized four- 
grain solution of atropin (Fig. 191) should be instilled 



502 



PREVALENT DISEASES OF THE EYE. 



every three or four hours, and the eye should be closed 
with a pad of gauze, wet with a i : 8000 sublimate 
solution, or a sterilized lotion of opium and boracic 
acid, and a light bandage. 

Non-magnetic foreign bodies should be located, if 
possible, by means of oblique illumination, the ophthal- 
moscope, or skiagraphy, and removed, through a suit- 
ably placed incision, with toothless forceps, a traction 
hook, or a small curet. 



Size of body by by mm. 

Situation , 
mmhack of centeT of cornea. 
mmJb elow horizontal plane . 
side of 



iran.ta. 




vertical plane. 



Horizontal 
section. 



Side view. Front view. 



Front view. 



Side view. 



Fig. 189. — Reduced drawing of Dr. Sweet's localizing chart, illustrating 
method of plotting position of foreign body in the eyeball. 

The removal of foreign bodies from the anterior 
chamber is not so easily accomplished as might appear 
at first sight. If magnetic they may, perhaps, be drawn 
out with a strong magnet through the wound of en- 
trance or through an incision made for the purpose. 
If they can not be removed in this way, they must be 
extracted with toothless forceps; but as the aqueous 



INJURIKS OF THK EYE AND APPENDAGES. 503 

humor escapes, and the anterior chamber is obliterated, 
as soon as an incision is made in the cornea, this is often 
a difficult procedure. Indeed, when the foreign body is 
embedded in the iris it is frequently necessary to remove 
the portion of the iris to which it is attached — that is to 
say, to perform an iridectomy. 

In an unusual case which came under my observation 
some years since, as the result of a blow from a chip of 
wood an eyelash was driven through the cornea into 
the anterior chamber, and lay, across the pupil, upon 




Fig. 190. — Sweet's electro-magnet. 

the surface of the iris. With considerable difficulty 
it was removed through a peripheral corneal incision, 
without injury to the iris, and, though a slight anterior 
synechia was left, useful vision was preserved. 

Exceptionally, and particularly in gunshot wounds, 
a foreign body may pass through the posterior, as well as 
the anterior, coats of the eye, and lodge in the orbit, 
and in other exceptional instances it may lodge in the 
orbit without wounding the eyeball. Its removal, 



5°4 



PREVALENT DISEASES OF THE EYE. 



under such circumstances, is difficult of accomplish- 
ment, and may not be necessary, unless it proves a 
source of irritation. 

Wounds of the eyeball caused 
bv penetrating foreign bodies 
are sometimes so extensive or of 
such a character that enucleation 
is clearlv called for, the mere 
removal of the foreign body 
offering no hope of preserving 
sight. This is especially true of 
lacerated wounds of the cornea 
and ciliarv region, such as are 
produced bv jagged pieces of iron 
or steel, struck from the edge of 
a hammeror chisel, riving against 
the eve with great force. In 
such cases removal of the eve is 

-F^rence flask the onlv procedure to be thought 
for sterilizing coliyria (about of; and it can not be done too 

quickly, for delay means not only 
much needless suffering, but the 
added risk of svmpathetic ophthalmitis. 




two-thirds actual size) 
foot-note.* 



See 



* This flask, fitted with a " Barnes eve-dropper," I greatly prefer to 
the Stroschein flask commonly used, for it is not only less expensive, 
but much less fragile. The mouth of the flask is plugged with cotton, 
in the usual manner, when the solution is being boiled. The eye- 
dropper is boiled separately, and, when the solution has cooled, is fitted 
quickly into the flask. The neck of the i-ounce flasks, as they are 
found on the market, is too large to fit the Barnes eye-dropper; but 
Messrs. Whitall, Tatum & Co., of Philadelphia, who furnish them, 
will " draw it in " to the size desired. 



* APPENDIX, 

The following formulae, for the most part in general 
use, are indicated, and will be found efficacious, in the 
conditions mentioned. 

COLLYRIA. 
To be applied by means of an eye-dropper, preferably 
one with a bent tip. Except when solutions of atro- 
pin, hyoscyamin, and other such poisonous drugs are 
prescribed, they may be instilled freely, and it is not 
necessary to direct exactly how many drops should be 
used. 

Acid, boracic gr. x 

Aquae destil § j. 

A few drops three or four times a day. 

Hyperemia of the conjunctiva, mild conjunctivitis, 
inflammation of the conjunctiva following injuries, 
operations, the intrusion of foreign bodies, etc., and for 
the relief of smarting and burning of the eyes. 

Acid, boracic gr. x 

Aquae camphor 3ij 

Aquae destil 3 vj. 

A few drops three or four times a day. 
Hyperemia of the conjunctiva, and for the relief of 
smarting and burning of the eyes. 

Sodii chlorid gr. iij-v 

Aquae destil 5 j- 

Indicated in the same conditions, and to be used in 
the same manner, as the foregoing. 

5°5 



506 PREVALENT DISEASES OF THE EYE. 

Acid, boracic gr. xviij 

Aq. destil 3 j. 

For cleansing the eye and for instillation every hour 
or half hour in purulent ophthalmia, and for less fre- 
quent instillation, in connection with other remedies, 
in ulcerative and suppurative keratitis. 

Zinci sulphat gr. ss 

Acid, boracic gr. x 

Aquae destil 5 j- 

A few drops three times a dav. 
Catarrhal and follicular conjunctivitis. 

Hydrarg. bichlorid gr. y 1 ^ 

Sodii chlorid gr. iij-v 

Aquae destil § j. 

A few drops three times a dav. 

Vernal catarrh, follicular conjunctivitis, and blennor- 
rhea of the lacrimal sac. In the last-mentioned con- 
dition, to be dropped into the inner corner of the eye, 
after pressing out the contents of the sac. 

Alum gr. iij 

Acid, boracic gr. xij 

Aquae destil 5 j- 

A few drops morning and night. 

For habitual application to the conjunctival sac when 
an artificial eye is being worn. 

Sol. Protargol 40% 

For daily application, with cotton mop or eye-dropper, 
in purulent ophthalmia, and every second day in acute 
stage of trachomatous conjunctivitis. 

Sol. Argyrol 40% to 50% 

Indications the same. May be applied as often as 
three times a day in purulent ophthalmia. 



APPENDIX. 507 

Sol. Protargol 10% 

For application twice daily in purulent ophthalmia, 
in addition to the daily application of the stronger solu- 
tion, and for use, two or three times a day, in trachoma- 
tous conjunctivitis. 

Sol. Argyrol 20% 

Indications the same. May be used more freely. 

Sol. Argyrol 5% or 

Protargol 2% 

Drop into the inner corner of the eye three times a 
day, after pressing out the contents of the lacrimal sac. 
Blennorrhea of the lacrimal sac. 

Aqua chlorinii (freshly prepared). 

To be dropped into the eye, if practicable upon the 
cornea, every three hours. 

Infected corneal ulcer, whether of idiopathic or trau- 
matic origin. 

Holocain hydrochlorat i gr. j 

Acid, boracic gr. x 

Aquae destil § j. 

A few drops every three hours. 
Ulcer of cornea. 

Atropiae sulphat gr. j 

Acid, boracic gr. x 

Aquae destil § j. 

One or two drops three times a day. 
Phlyctenular conjunctivitis and keratitis and other 
mild forms of keratitis. 



508 PREVALENT DISEASES OF THE EYE. 

Atropiae sulphat gr. ij 

Acid, boracic gr. x 

Aquae destil 5 j. 

In like conditions, when photophobia and lacrimation 
are more marked. 

Atropiae sulphat gr. iv 

Acid, boracic gr. x 

Aquae destil 3 j- 

One or two drops every three hours. 

Iritis, cyclitis, severe keratitis, or sclero-keratitis, and, 
three times daily, in episcleritis, sclero-conjunctivitis 5 
and interstitial keratitis. 

Atropiae sulphat gr. \ 

Acid, boracic gr. x 

Aquae destil 5 j- 

One or two drops every third day. 

To improve the vision in incipient cataract, when the 
opacity of the lens is chiefly central, by maintaining 
semi-dilation of the pupil. 

Atropiae (alk.). . . . .gr. iv 

Ol. ricini 5j- 

One or two drops three or four times a day. 
Burns of the cornea and conjunctiva. 

Eserin sulphat gr. ij — iv 

Acid, boracic gr. x 

Aquae destil 5 j- 

One or two drops three or four times a day. 
Inflammatory glaucoma. 

Eserin sulphat gr. \-\ 

Acid, boracic gr. x 

Aquae destil § j. 

One or two drops morning and night. 
Glaucoma simplex, chronic glaucoma, and in inflam- 
matory glaucoma between exacerbations. 



APPENDIX. 509 

Pilocarpin hydrochlorat gr. iv-viij 

Acid, boracic gr. x 

Aquae destil 5 j- 

One or two drops three or four times a day. 
Inflammatory glaucoma, when eserin is not well 
borne. 

Pilocarpin hydrochlorat gr. j-ij 

Acid, boracic gr. x 

Aquae destil § j. 

One or two drops two or three times a day. 

As a substitute for the weaker solution of eserin, in 
glaucoma simplex, chronic glaucoma, and in inflamma- 
tory glaucoma between exacerbations. 



Sol. Dionin. 



'0 



One or two drops two or three times a day. 

Iritis and keratitis, in conjunction with atropin, in- 
flammatory glaucoma, in conjunction with eserin, and 
to promote the absorption of recent corneal opacities, 
of inflammatory exudates in the anterior chamber, and 
of extruded cortical lens substance, after cataract 
operations or wounds of the lens. 

Hyoscyamin hydrobromat gr. ij 

Aquae destil 5 j. 

One or two drops every three or four hours. 

Iritis, keratitis, etc., as a substitute for atropin, when 
atropin is not well borne. Also as a cycloplegic in 
determining refractive errors. When used for this 
purpose, two applications of a single drop, an hour or 
two apart, should be made the evening before, and 
three applications, at similar intervals, during the fore- 
noon of, the day on which the examination is to be made. 



510 PREVALENT DISEASES OF THE EYE. 

Homatropiae hydrobromat gr. ij 

Aquae destil 3ij- 



An evanescent and but slightly toxic cycloplegic, used 
in measuring refractive errors. Three applications at 
half-hour intervals the evening before, and seven or 
eight applications the morning of, the examination, the 
last three twenty minutes apart, the others at intervals 
of an hour. 

Homatropiae hydrobromat gr. ij 

Aquae destil §ss. • 

One or two applications. 

An evanescent mydriatic. To facilitate ophthalmo- 
scopic examinations, to permit inspection of the lens 
in suspected cataract, and to determine the presence of 
iritis. 

Euphthalmin hydrochlorat gr. vj 

Aquae destil = . . 3ij- 

A transient mydriatic, to be used in the same way, 
and for the same purposes, as the foregoing. 

Cocain hydrochlorat gr. xx (4%) 

Acid, boracic gr. xv 

Aquae destil 5 j- 

Three to five applications, at intervals of two or three 
minutes. 

To induce anesthesia. In all important operations 
should be sterilized by boiling before being used. Dis- 
tinctly objectionable, and not to be employed, as a 
therapeutic agent. 



APPENDIX. 511 

Holocain hydrochlorat gr. x (2%) 

Aquae destil 5j- 

A local anesthetic, to be applied in the same manner 
as cocain, and to be used as a substitute for it when it is 
desirable to avoid the mydriasis and the disturbance of 
the corneal epithelium which cocain produces. Is in 
itself an antiseptic. 

Sol. Hydrarg. bichlorid 1 : 8000. 

For sterilizing the eye preparatory to operations. 
Several hours before the time fixed for the operation 
the lids should be cleansed with soap and water, the 
conjunctival sac flushed with this solution, and a gauze 
pad wet with it bound over the lids. The flushing of 
the conjunctiva should be repeated three times, at inter- 
vals of about an hour, before the operation is begun. 



LOTIONS. 
To be applied on absorbent gauze, or soft linen, pads 
over the closed lids. 



Saturated Solution of Boracic Acid. 

Acid, boracic gr. lxxij 

Aquae destil 5iv. 

Useful in wounds of the lids and eyeball, after enucle- 
ation of the eye, in lid abscess, etc. By covering the 
pad with oiled-silk or oiled-muslin a cleanly and excel- 
lent poultice is provided. 



512 PREVALENT DISEASES OF THE EYE. 

Lotion of Opium and Boracic Acid. 

(Frequently commended in the text.) 

Ext. opii gr. x 

Acid, boracic gr. xl 

Aq. destil 5iv. 

Valuable in any painful condition of the eye, espe- 
cially in traumatic lesions, in keratitis, iritis, glaucoma, 
acute inflammation of the lacrimal sac, lid abscess, pan- 
ophthalmitis, cellulitis of the orbit, etc. Also useful in 
asthenopia, in miliary choroido-retinitis, dependent 
upon strain of accommodation, and in the choroido- 
retinitis of high myopia. May be given a poultice-like 
action by covering the pad on which it is applied with 
oiled-silk or oiled-muslin. May be applied hot if found 
more soothing. 

Lotion of Belladonna. 

Ext. belladonna? '. gr. xv 

Aquae destil 5* v - 

Iritis, cyclitis, keratitis, etc. 

Sublimate Solution. 

Hydrarg. bichlorid gr. j 

Aquae destil Oj. 

Wounds of the lids and eyeball. The lids should first 
be bathed, and the conjunctival sac flushed, with this 
same solution. 

Hot Water. 

Interstitial keratitis, iritis, and glaucoma. Should 
be applied as hot as can be borne without complaint. 

Iced Water. 

Pads of gauze should be kept lying upon a block of 



APPENDIX. 513 

ice, and a fresh pad should be applied to the eye at short 
intervals. 

Purulent ophthalmia in the adult. 



OINTMENTS. 

"Vaselin Cerate. " 

Cerae flav 1 part 

Vaselin 4 parts. 

To be melted together, and stirred while cooling. 

A useful base, of proper consistency and with little 
tendency to become rancid, for ointments to be applied 
to the lids. 

Hydrarg. ox. flav gr. viij 

Vaselin cerate Sss. 

To be applied to the lids at bedtime, after removing 
any crusts that may be present by bathing with warm 
water. 

Blepharitis marginalis and eczema of the lids. 

Hydrarg. ox. flav gr. iv 

Vaselin 5 ss. 

A piece the size of a rice-grain to be applied to the eye 
once a day, preferably in the morning. The application 
can be conveniently made with a flat wooden toothpick 
or, by untrained hands, with a small camel's-hair brush. 

Phlyctenular conjunctivitis and keratitis, vernal 
catarrh, chronic trachoma with pannus. 

Zinci oxid. 

Acid, boracic aa 3ss 

Vaselin cerate 5ss. 

To be applied morning and night. 

33 



514 PREVALENT DISEASES OF THE EYE. 

Eczema of the lids. 

Acid, salicylic gr. iv-viij 

Vaselin cerate 5 SS - 

To be applied morning and night. 

Eczema of the lids, and, exceptionally, in blepharitis 
marginalis, when the yellow oxid of mercury ointment 
fails to cure. 

Ext. belladonna? 5j 

Ung. hydrarg § j. 

To be rubbed upon the forehead and temples three 
times a day. 

Syphilitic iritis and irido-cyclitis, sympathetic ophthal- 
mitis. 



AGENTS TO BE APPLIED, WITH EXACTNESS, TO THE EYE 

OR LIDS. 

Acid, carbolic. 

For application to infected corneal ulcers or wounds, 
and to abort styes. 

A very small quantity of the acid should be applied 
directly to the ulcer (the eye being under the influence 
of cocain) by means of a sharp-pointed, wooden tooth- 
pick, armed with a few fibers of absorbent cotton. 
After the application the eye should be flushed with a 
boracic acid or normal salt solution. In the treatment 
of styes, the point of the toothpick, after having been 
dipped into the acid, should be insinuated as far as 
possible into the infected follicle, which can generally 
be recognized upon the lid-margin. 

Tinct. iodin. 



APPENDIX. 515 

To be applied in the same careful way as carbolic 
acid. 

Infected corneal ulcers. 

Zinci sulphat gr. xxx 

Aquae destil o ]• 

Should be applied with the finger-tip, every half-hour, 
to the external surface of the lid, over the sensitive area, 
care being exercised not to let the solution enter the eye. 

To abort styes. 

Pointed crayon of silver nitrate. 

To be applied lightly to the lid-margin after removal 
of crusts. 

Blepharitis marginalis. 

Copper sulphate crystal. 

For application to the conjunctival surface of the 
everted lids, every second or third day. 
Chronic trachomatous conjunctivitis. 

Veratriae Oleat io c " c 

A little to be rubbed upon the forehead and temples 
once a day, preferably in the morning. Care should be 
exercised to prevent its getting into the eye, as this 
causes severe and persistent irritation. 

Asthenopia and frontal headache due to accommo- 
dative or muscular strain. To lessen the irritability of 
the ciliary muscle preparatory to testing errors of refrac- 
tion. 



5l6 PREVALENT DISEASES OF THE EYE. 

CONSTITUTIONAL REMEDIES. 
Elix. ferri et quiniae et strychniae phosphat. (Wyeth's.*) 

A teaspoonful three times a day for adults; for chil- 
dren two-thirds to one-third of a teaspoonful, according 
to age. When less than a teaspoonful is prescribed, it 
should be diluted to the required degree with elix. sim- 
plex, so that the quantity to be given shall be one tea- 
spoonful. 

Phlyctenular conjunctivitis and keratitis, eczema of 
the lids, and eczematous blepharitis marginalis. 

Syr. ferri et quiniae et strychniae phosphat. (Sharp and 
Dohme's.*) 

Dose and indications for administration the same as 
the foregoing. May be diluted with simple syrup. 

Quiniae sulphat. in three-grain capsules. 

One every three or four hours. 

Ulcer and abscess of the cornea, herpetic keratitis, 
purulent iritis, and threatening panophthalmitis. 

Ext. nucis vom gr. x 

Quiniae sulphat gr. xl-lxxx 

Ferri carbonat. (Vallet's) gr. lxxx. 

Ft. capsules xl. 

One three times a day. 

A well-known tonic combination, often found useful 
in the treatment of eye diseases. 

Tinct. nucis vom 5 j 

Tinct. cinchonae compos §xj. 

Two teaspoonfuls three times a day. 

* These particular preparations are mentioned because they con- 
tain a considerably larger proportion of iron and quinin than most 
of the preparations which are sold under the same name. 



APPENDIX. 517 

Another excellent tonic combination, especially use- 
ful in asthenopia following exhausting diseases. 

Syr. ferri iodic! . 

Eight to twenty drops, in a wineglassful of water, 
three times a day. 

Phlyctenular conjunctivitis and keratitis, accom- 
panied by definite signs of struma. 

Potassii iodid. (saturated solution). 

In increasing doses. 

Rheumatic and syphilitic inflammations of the eye, 
especially those occurring in the tertiary stage of 
syphilis, uveitis, sclero-keratitis, scleritis, paralysis of 
the ocular muscles, and to promote the absorption of 
blood in the vitreous or anterior chamber, and of cortical 
lens substance after cataract operations or injuries of 
the lens. 

Hydrarg. biniodid gr. j-ij 

Potassii iodid gr. x 

Aquae 5iv. 

A teaspoonful three times a day, after meals. 

Syphilitic affections of the iris, ciliary body, choroid, 
retina, and optic nerve; especially those occurring during 
the secondary stage of the disease; also in glaucoma, 
retrobulbar neuritis, sympathetic ophthalmitis, etc. 
When prompt action is demanded, its administration 
may be supplemented by inunctions of mercurial oint- 
ment, and when thought desirable the proportion of 
potassium iodid may be increased, so that the dose pre- 
scribed shall contain five to ten grains. 

Hydrarg. biniodid gr. j 

Potassii iodid gr. x-c 

Syr. ferri iodid 5ss 

Aquae 5»jss. 



518 PREVALENT DISEASES OF THE EYE. 

A teaspoonful, in a wineglassful of water, three times 
a day, after meals. 

Interstitial keratitis and other chronic syphilitic af- 
fections. 

Hydrarg. bichlorid gr. j 

Tinct. ferri chlorid §ss 

Aquae 5 n jss. 

A teaspoonful, in a wineglassful of water, three times 
a day, after meals. 

A useful substitute for the foregoing, especially when 
the iodides are not well borne. 

Potassii iodid gr. lxiv-xcvj 

Syr. ferri iodid 3ss 

Aquae 5iijss. 

A teaspoonful, in a wineglassful of water, three times 
a day, after meals. 
Interstitial keratitis. 

Tablet triturates of calomel (gr. 3— |). 

One every two hours, guarded by opium if found 
necessary, and supplemented by inunctions of mercurial 
ointment. 

When prompt mercurialization is called for, as in 
severe syphilitic inflammation of the iris, choroid, retina, 
optic nerve, etc., and in sympathetic ophthalmitis. 

Sodii salicylat. (In solution or in capsules.) 

. Ten grains every two or three hours. 

Iritis, cyclitis, scleritis, sclero-conjunctivitis, espe- 
cially when they are dependent upon a rheumatic dia- 
thesis, acute glaucoma, inflammation of the uveal coat 
due to traumatism, whether accidental or operative, 
and in much larger doses, pushed to the point of 
toleration, in sympathetic ophthalmitis. 



APPENDIX. 519 

Strychnia? sulphat. (In solution or in tablet triturates.) 

In increasing doses, to be given directly after meals. 
Incipient atrophy of the optic nerve or retina, chronic 
retrobulbar neuritis, paralysis of the ocular muscles. 

Pilocarpin hydrochlorat gr. iv 

Aquae 5ss. 

Ten drops once a day, the dose on each succeeding 
day to be increased by two or three drops, according to 
the effect produced. 

Choroido-retinitis, uveitis, glaucoma, detachment of 
the retina. 

Sodii pyrophosphat § j 

Aquae 5 xij. 

A tablespoonful, in water, every two or three hours. 
Acute inflammation of the lacrimal sac, cellulitis of 
the orbit, abscess of the lid. 

Natural lithia water. 

To be drunk freely. 

Gouty affections of the eye — scleritis, iritis, retinitis, 
etc. 



"Compound Calomel Powder." 

(Frequently mentioned in the text.) 
Hydrarg. chlorid. mitis gr. ij-i 



iv 



Pulv. scammonii gr. ij 

Pulv. rad. rhei gr. vj. 

Ft. capsules ij (or may be given in powder form). 

The two capsules, or the whole powder, to be given at 
bedtime. The dose may often be repeated with advan- 
tage after forty-eight hours. 



520 PREVALENT DISEASES OF THE EYE. 

As a first measure in the treatment of phlyctenular 
kerato-conjunctivitis, especially when there is attendant 
eczema of the lids, face, etc., also in acute glaucoma, 
iritis, and whenever an energetic purgative is called for. 

Tablet triturates of aloin (gr. yV~i)' 

One to be taken at bedtime. 
Habitual constipation. 



INDEX. 



Note. 



-The bold-face type indicates the pages on which the subjects 
are especially treated of (or considered) . 



Abducens, paralysis of. See Pa- 
ralysis 0} external rectus muscle. 
Ablatio retinae. See Retina, detach- 
ment of. 
Abscess and ulcer of cornea, 207 
of lacrimal sac. See Dacryo- 
cystitis. 
of orbit, 108 
prelacrimal, 137 
Accommodation, 426 
abnormal power of, 428 
anomalies of, 425 
different ways in which may be 

impaired, 427 

disturbance of normal relationship 

between convergence and, 396 

in hypermetropia, 396, 397, 400 

asthenopia caused by, 396 

convergent squint caused by, 

397 
in myopia, 407, 408 

asthenopia caused by, 408 
divergent squint caused by, 

408 
in subnormal accommodative 
power, 434, 435 
asthenopia caused by, 

435 
how remedied, 436 
failure of, from advancing age, 427 
Helmholtz's theory of, 426 
mechanism of, 426 * 

normal relationship between con- 
vergence and, 396 
how disturbed in hypermetropia, 

39 6 
in induced cycloplegia, 435 
in myopia, 407, 408 
in subnormal accommodative 
power, 434, 435 
paralysis of, 427. See also Pa- 
ralysis of ciliary muscle. 
symptoms which indicate, 32 
progressive decline of, 427, 428 



Accommodation, rapid failure of, an 

early symptom of glaucoma, 279 

spasm of, 427. See also Spasm 

of ciliary muscle. 
subnormal power of, 427. See 
also Subnormal accommodative 
power. 
Accommodative power, subnormal. 
See Subnormal accommodative 
power. 
Acromegaly in etiology of hemian- 
opsia, 386 
Actual cautery in corneal ulcers, 214 
Adrenalin in operation for ptery- 
gium, 10 1 
in recurrent intraocular hemor- 
rhage, 337 
in treatment of strictures of nasal 
duct, 143 
Advancement of muscle in conver- 
gent squint, 457 
in divergent squint, 465 
in exophoria, 472 
in heterophoria, 471 
After-cataract. See Cataract, cap- 
sular. 
Age, influence of, in development of 
convergent squint, 402, 439, 
448 
in diseases of choroid and ret- 
ina, 339 
in glaucoma, 276 
in interstitial keratitis, 223 
in myopia, 407, 412 
upon cataract, 298, 299, 301, 

313, 314, 318 
upon hypermetropia, 398, 401 
upon the accommodation, 426, 

427, 428, 429 
upon the crystalline lens, 295,296 
Agents for exact application to eye 

or lids, 514, 515 
Albuminuric retinitis. See Retinitis, 
albuminuric. 



52i 



522 



INDEX. 



Alcohol, methylic, in retrobulbar 

neuritis, 374 
Alcoholism in hyperemia of conjunc- 
tiva, 153 
in retrobulbar neuritis, 376 
Aloin in habitual constipation, 520 
in recurrent hordeola, 69 
in retinal hemorrhage, 337 
Alternating strabismus. See Squint, 

alternating. 
Alum and boracic acid, formula for 
collyrium of, 506 
after enucleation of eye, 273, 

506 
in blennorrhea of lacrimal 
sac, 148 
crystal in trachoma, 181 
"Amaurotic cat's eye. " See Retina, 

glioma of. 
Amblyopia exanopsia, 319, 449 
misuse of term, 449 
of squinting eye, how induced, 449 
toxic. See Optic neuritis, retro- 
bulbar, chronic. 
uremic, 351 
Ametropia, 394 
definition of, 394 
varieties of, 394 
Ammonium chlorid in treatment of 

stricture of nasal duct, 149 
Amnion's, von, operation for short- 
ening lid, 93 
Anagnostakis-Hotz operation for 

entropion, 86 
Anatomy of cornea, 204 
of crystalline lens, 295, 296 
of eyelids, 68 

of iris and ciliary body, 251 
of lacrimal apparatus, 118, 121, 

126, 137 
pathological, of glaucoma, 283, 
284 
of interstitial keratitis, 224, 225 
of stenosis of nasal duct, 125, 

137. 138 
of trachomatous conjunctivitis, 

175, 176, 177, 178, 180 
of ulcerative keratitis, 205, 206, 
207, 209, 210 
Ankyloblepharon, 480, 483 
Anemia, acute, thrombosis of retinal 
artery in, 359 
pernicious, retinitis in, 352 
Anesthesia from cocain, 51, 510 
and adrenalin, 101, 143 
from holocain, 511 
general, in enucleation of eye, 2 70 

in tenotomy in children, 461 
of cornea, how determined, 35 



Anesthesia of cornea, in glaucoma, 
277 
in neuropathic keratitis, 217 
Angiosclerosis, 291, 302 
Angle alpha in hypermetropia, 453, 

454 
Anisometropia, 424 

a factor in causation of strabis- 
mus, 424 
consequences of, 424 
definition of, 424 
difference in size of pupils due to, 

2 5 

exceptionally a blessing in dis- 
guise, 424 

treatment of, 424, 425 
Anomalies, muscular. See Muscu- 
lar anomalies of the eyes. 

of accommodation, 425 

of refraction, 388 

and accommodation, 388 
etiological importance of, 389, 

39o 

general observations upon sig- 
nificance of, 388 

harm which results from 
unskilful correction of, 388, 

389 

prevalent misconceptions re- 
garding, 390, 391, 39 2_ 

special skill and training re- 
quired in correction of, 388 
Anterior chamber, examination of, by 
oblique illumination, 37, 500 

eyelash lodged in, 503 

filtration angle of, 282 

alteration of, in glaucoma, 
283, 284 

inspection of, 35 

obliteration of, in glaucoma, 278 

paracentesis of, 215 

pus in, 211, 215 

removal of foreign bodies from, 

503 
polar cataract, 320 
staphyloma. See Staphyloma of 

cornea. 
synechia. See Synechia, anterior. 
Antisepsis in wounds of eye, 495, 501 
preparatory to operations upon 
eye, 327, 461, 511 



Antiseptic agents, 50, 



;n, 5 12 



Antitoxin, diphtheria, 61 
Apothecaries, a reprehensible habit 

of, 43 
Appendix. 505 

Application of carbolic acid to eye. 
See Carbolic acid, application of. 

of collyria, 41, 42, 43, 44 



INDEX. 



523 



Application of ointments to eye and 

lids, 45 
Aqueous humor, inspection of, 35, 36 
lessened transparency of, in 
iritis. 247 
Arcus senilis. 235 

pathology of, 235 
Argyll Robertson symptom, 27, 379 
Argyria conjunctiva?, 193 
etiology of, 193 
signs of, 193 

treatment of no avail in, 193 
Argyrol, 51. 157 

in dacryocystitis, 137 
in purulent conjunctivitis, 164 
Argyrosis. See A rgyria conjunctiva. 
Arlt's operation for ectropion, 95 

tenotomy, 457, 465 
Arsenic in herpes zoster ophthalmi- 
cus, 266 
in neuropathic keratitis, 222 
in retinitis of pernicious anemia, 

.353 
Artificial eye, 241, 273, 506 
pupil, 238, 267, 325, 326 
Associated ocular paralyses, 446 
Asthenopia, symptoms characteristic 

of, 32 
Astigmatism, 413 

according to the rule, 415 

usually located in cornea, 415 
acquired, 417 

advantages and disadvantages of a 
cycloplegic in determination of, 
422, 423 
a factor in the causation of cata- 
ract, 303, 345 
of glaucoma, 285, 345 
of miliar}- choroido-retinitis, 

343 
of myopia, 406 
after cataract extraction, 417 
against the rule, 415 

special significance of, 285, 

415, 416, 417 
usually located in lens, 415 
apparent increase of, how ex- 
plained, 416 
a significant amount of, not incom- 
patible with normal acuteness 
of vision, 417 
asthenopia, how caused by, 414 
compound, 415 
consequences of, 285, 303, 343, 

345, 406, 418 
corneal, 415 
correction of, by cylindrical glasses, 

419, 420 
definition of term, 413 



Astigmatism, increase of, 416 

irregular, 237, 413 

latent, 414, 416 

explanation of, 414 

how rendered manifest, 416 

lenticular, 415 

manifest, 416 

may be acquired, 417 

may be due to asymmetry or ob- 
liquity of crystalline lens, 413 

measurement of, 421, 422 
by skiascopy, 422 
with lenses, test-type, and astig- 
matic dial, 422 
with ophthalmometer, 422 
with ophthalmoscope, 421 

mixed, 415 

nature of visual disturbance in, 

4i3' 4i4 
often inherited, 413 
often mistaken for myopia, 415 
one of the commonest reiractive 

anomalies, 413 
orientation of, 416 
principal meridians in, 416 
regular, 413 
seat of, 413 
simple, 415 

method of detecting pronounced 
degrees of, 417, 418 
static, 414 

symptoms of, 414, 415 
the cornea the usual seat of, 413 
the ophthalmometer an untrust- 
worthy means of measuring, 422 
treatment of, 419 
usually a congenital fault, 413 
varieties of, 413, 415 
Astringents and antiseptics, indica- 
tions for employment of, 40 
Atresia of canaliculi, 130 
of lacrimal puncta, 1 26 
Atrophy of conjunctiva, 176 
of eyeball from glaucoma, 280 
from penetrating wounds of 

globe, 495, 496 
from purulent panophthalmi- 
tis, 334 
. of lacrimal gland, 1 24 
of optic nerve, 378 

inflammatory, 381 
non-inflammatory, 378 
of retina, in retinitis pigmentosa, 

355 
Atropin, 46 

and boracic acid collyria, 507, 508 
follicular conjunctivitis from pro- 
longed use of, 48 
glaucoma induced by, 47, 288 



524 



INDEX. 



Atropin, idiosyncrasies displayed 
towards, 48, 261 
indications for employment of, 40, 

46 
persistent effect of, 47 
to be used with caution in serous 

iritis, 261 
weak solutions of, in incipient cat- 
aract, 311 
Author's crochet-pointed strabis- 
mus hook, 458 
doctrine of subnormal accommo- 
dative power, 433 
eye-bandage, 55 

lacrimal probe for use by patients, 
149 
probes, 141 
measurements of nasal ducts, 141 
needle-holder, 459 
series of cataract extractions, 316 
supplementary lacrimal probe, 145 
theory of the etiology of post-hem- 
orrhagic blindness, 359 
of the genesis of pterygium, 198 
views on the amblyopia of squint- 
ing eyes, 449, 450, 451 
on the genesis of sympathetic 
ophthalmitis, 258, 259 
Auto-infection, 208 



Bacillus, Klebs-Loffler, 170, 211 

Weeks, 156 
Bader's scleral fixation forceps, 270, 

272 
Bandage, Author's eye, 55, 56 
Bandages, eve, indications for use 

of, 56 
Basham's mixture, 351 
Belladonna and mercury, ointment 
of, 514 

lotion of, 512 
Bichlorid of mercury. See Mercury, 

bichlorid. 
Bifocal lenses, 421, 430 
cemented, 430 
invisible, 430 
Blennorrhea of lacrimal sac, 132 
Blepharitis marginalis, 63, 389, 467 

etiology of, 64, 65 

treatment of, 65, 66 
Blepharo-adenitis, 63 
"Blind spot," enlargement of, in 

choked disc, 371 
Blindness, monocular, often present 

without knowledge of patient, 33 
Blisters in acquired ptosis, 100 

in paralysis of facial nerve, 107 
of sixth nerve, 443 



Blisters in retrobulbar neuritis, 375 
Bonnet, operation of enucleation of 

eye devised by, 269 
Boracic acid, after removal of ptery- 
gium, 200 

conditions in which, is useful, 51 

formulae for collyria of, 504 

in asthenopia, 51 

in corneal ulcers, 212 

in diphtheritic conjunctivitis, 



conjunctivitis, 



in hyperemia of conjunctiva, 153 
in keratomalacia, 216 
in membranous 

169 
in mild catarrhal conjunctivitis, 

in phlyctenular conjunctivitis, 

190 
in superficial injuries of cornea, 

485 
ointment of, 157 
saturated solution of, 511 

conditions in which, is 

useful, 511 
in purulent conjunctivitis, 

163 
in wounds of the lids, 482 
use of, as a poultice, 53, 511 
Bowman's membrane, 204 
never regenerated, 203 
operation for fistula of lacrimal 
gland, 121 
for ptosis, 102 

of division of canaliculus, 140 
probes, inadequate size of, 140 
Bull, C. S., 266, 292 
: Buller's shield, 166 
Buphthalmos, 276 

characterized by general enlarge- 
ment of eyeball, 276 
etiology of, 276 
Burns of conjunctiva, 481, 482, 483 
entropion from, 482 
symblepharon from, 4S 
treatment of, 482, 483, 
of cornea, 485 

consequences of, 485 
leucoma from, 485 
treatment of, 485, 486 
of lids, 481 

ectropion from, 481 
from gunpowder, 483 
treatment of, 482, 483 
Thiersch grafts in, 483 



Calomel purge, value of, in inflam- 
matory affections of the eye, 61 



484 



INDEX. 



525 



Canal of Schlemm, 282 
Canaliculi, atresia of, 1 30 
etiology of, 130 
treatment of, 130 
Canaliculus, division of lower, 128 
of upper, 130 
foreign bodies in, 131, 448 
knife, Weber s, 129 

modified, 129 
polypus in, 131 
Capsular cataract. See Cataract, 

capsular. 
Carbolic acid, application of, to cor- 
neal ulcers, 51, 213, 214, 215, 

in treatment of hordeolum, 70, 

Caries of orbit, 1 1 1 
treatment of, 113 

hydrochloric acid in, 113 
resulting from stricture of nasal 
duct, 148 
Castor oil in burns of the eye, 54 
solution of atropin in, indica- 
tions for use of, 54 
Cataract, 297 

accommodative strain in causa- 
tion of, 303, 344, 389 
amber-colored, characteristics of, 

3 OI > 309 

anterior polar, 320. See also Cat- 
aract, pyramidal. 

black, 301 

Brisseau's discover}' of true na- 
ture of, 298 

capsular, 326 
diagnosis of, 327 
etiology of, 326 
treatment of, 327 

couching of, 314 

discission of, as formerly practised, 

3 X 4 

as now performed, 314 
encountered oftenest in the aged, 

298 
erroneous ideas long prevalent as 

to nature of, 297 
extraction of, 314, 315 

combined, 315 

linear, 319 

prognosis in, 316 

simple, 315 

suction, 319 
extractions, author's series of, 316 
Forster's operation in immature, 

3*3 
general, 299 

acquisition of "second-sight" a 
premonitory symptom of, 302 



Cataract, general, amblyopia conse- 
quent upon, 319 
capsular opacitv after extraction 

of, 318 
conditions which point to prob- 
able existence of, 307 
constitutional disorders which 
predispose to development of, 
302 
determination of maturity of, 

307, 308, 309 
diagnosis of, 304, 305 
errors in, 35, 305, 306 
help afforded by a mydriatic 
in, 304, 305 
by oblique illumination 

in, 304, 306 
bv ophthalmoscope in, 

305 
nature of visual impairment 

helpful in, 300, 307 
subjective symptoms to be 
considered in, 306, 307 

differences in rapidity of devel- 
opment of, 301 

due to degeneration of lens 
fibers, 302 

etiology of, 302, 303, 304 

normal response of pupil to light 
in, 300 

ocular diseases which predis- 
pose to, 303 

predisposition to, often inheri- 
ted, 302 

prenatal development of, 303, 

304 
traumatic lesions which tend to 

production of, 303 
treatment of, 310—320 

atropin in, 310 

only operative, of avail, 310 

post-operative, 316 

prophylactic, 310 

when immature, 313 

when only one eye is involved, 

3 I2 > 313 
variations in color of, 301 
varieties of, 299 
in detachment of retina, 363 
in high myopia, 342 
origin of name, 297, 298 
partial, 320 

definition of, 32c 
etiology of, 320, 321,322,323,324 
varieties of, 320 
posterior polar, 322, 356 
etiology of, 323, 324 
treatment of, 325 
varieties of, 323, 324 



526 



INDEX. 



Cataract, pyramidal, 321, 322 
etiology of, 321, 322 
vision in, 322 
ripeness of, 307 

secondary. See Cataract, capsu- 
lar. 
traumatic, 294, 299, 303,318,492, 

494, 498, 499 
varieties of, 298, 299 
zonular, 324 

diagnosis of, 325 
etiology of, 324 
impairment of vision in, 325 
treatment of, 326 
Catarrhal conjunctivitis. See Con- 
junctivitis, catarrhal. 
Cathartic, energetic, value of, in 

inflammations of the eye, 61 
Caustic potash, treatment of entro- 
pion of lower lid with, 82 
Cautery, actual, in corneal ulcers, 214 
Cellulitis of orbit, 108 
complications in, 109 
diagnosis of, 109 
etiology of, 108 
symptoms of, 108 
treatment of, 109 
Central artery of retina, embolism of. 
, See Embolism 0} central 

artery 0} retina. 
thrombosis of . See Thrombo- 
sis of central artery of retina. 
retinal vein, thrombosis of. See 
Thrombosis of central retinal 
vein. 
Chalazion, 73 

clinical history of, 73, 74 
diagnosis of, 73 
etiology of, 73 
operation for, 75 
treatment of, 74 
Childhood, glaucoma in, 276 
Children, examination of eyes of, 57 
Chlorin water in corneal ulcers, 212, 
.' 221, 507 
Choked disc, 370 

commonly caused by intracra- 
nial new-growths, 371 
consequences of, 371 
etiology of, 367, 368, 371, 372 
ophthalmoscopic picture of, 369, 

37° 
pathology of, 368, 369 
prolonged course of, 371 
sight often insignificantly im- 
paired in early stages of, 371 
symptoms of, 371 
treatment of, 373 
usually bilateral, 372 



Chorea, 390, 418 

Choroid coat, diseases of, 340 

retina, and optic nerve, diseases 
of, 338 
etiology of, 339 
impairment of vision 

i n > 33% 
prognosis in, 339, 340 
recognition of exist- 
ence of, without the 
aid of the ophthal- 
moscope, 338, 339 
symptoms indicative 

of > 33%> 339 
treatment of, to be 
directed to the un- 
derlying systemic 
cause, 339 
sarcoma of, 348 
tumors of, 348 

commonly of malignant type, 

348 
treatment of, 348 
Choroiditis, 340 

of high myopia, 342 

cataract a consequence of, 342 
characteristics of, 342 
detachment of retina in, 342 
impairment of vision in, 342 
treatment of, 346 
plastic, 340 
etiology of, 340 
of traumatic origin, 342 
etiology of, 342 
serious import of, 343 
sympathetic ophthalmitis 
" from, 343 
treatment of, 346 
varieties of, 340 
purulent, 340. See also Panoph- 
thalmitis, purulent. 
serous, 340. See also Iritis, 

serous. 
syphilitic, 340 

impairment of vision in, 340 
iritis frequently associated with, 

34o 

loss of transparency of vitreous 
humor in, 340 

occurs in inherited syphilis, 340 

pathological changes in, 340, 341 

symptoms of, 342 

treatment of, 345 
Choroido-retinitis, miliary, 343 

a common consequence of eye- 
strain, 343 

a factor in causation of cataract 
and glaucoma, 285, 303, 344, 
345 



NDEX. 



527 



Choroido-retinitis, miliary, deserving 
of more consideration than is 
commonly accorded it, 343 
etiology of/343 

ophthalmoscopic picture of, 344 
"patchy choroid" a result of, 

344 ' 
pathological changes in, 344 
symptoms of, 344 
treatment of, 347, 348 
Ciliary body, diseases of, 268 
hernia of, 494 
tumors of, 269 
muscle, insufficiency of, in sub- 
normal accommodative power, 

433. 435 
paralysis of, 430 
spasm of, 432 
Circumlental space, in glaucoma, 

284 
Clonic spasm of lids from reflex den- 
tal irritation and from phimosis, 
223 
Cocain hydrochlorate, formula for 
solution of, 510 
in treatment of stricture of nasal 

duct, 143 
valuable as an anesthetic, but 
not as a remedial agent per 
se, 51 
Colchicum, 244, 262 
" Cold" as a factor in causation of ca- 
tarrhal conjunctivitis, 1 56 
of dacryoadenitis, 1 19 
of dacryocystitis, 133 
of neuropathic keratitis, 219 
of paralysis of sixth nerve, 443 
of retrobulbar neuritis, 374 
Collyria, 40-44, 46-52 

application of, 41, 42, 43, 44 
contamination of, by apothecaries, 

43 
formulae for, 505-511 
precautions necessary in using 

poisonous, 43 
rose-water objectionable in, 44 
sterilization of, 501 
"Compound calomel powder," for- 
mula for, 519 
in acute dacryoadenitis, 120 
in acute dacryocystitis, 136 
in blepharitis, 66 
in glaucoma, 289 
in phlyctenular conjunctivitis, 

192 
in recurrent hordeola, 71 
Concomitant squint, 448. See also 

Squint, concomitant. 
Condylomatous iritis, 255 



Conical cornea, 241 

galvano-cautery in, 242 
marked impairment of vision in, 

241 
myopia of high grade, a conse- 
quence of, 241 
symmetrical aberration in, 241 
treatment of, 241 
Conjugate ocular paralyses, 446 
etiology of, 446, 447 
pathology of, 446, 447 
symptoms of, 446, 447 
treatment of, 447 
varieties of, 446 
Conjunctiva, diseases of, 151, 467 
hyperemia of, 152 
injuries of, 481, 482, 483 
Conjunctivitis, 154 
catarrhal, 154 
acute, 155 

bacteriology of, 156 
diagnosis of, 155 
etiology of, 156 
nearly always binocular, 155 
prognosis in, 156 
treatment of, 157 
chronic, 157 
etiology of, 157 
treatment of, 157 
croupous, 168 

character of membrane in, 169 
etiology of, 168 
symptoms of, 169 
treatment of, 169 
diagnostic signs and symptoms of, 

151 
diphtheritic, 169 

atypical forms of , 171 

bacteriology of, 170, 172 

character of membrane in, 170 

consequences of, 171 

entropion from, 171 

infection, modes of, in, 171 

symptoms of, 170 

treatment of, 172 
follicular, 173 

pathology of, 173 

symptoms of, 173 

treatment of, 173 
gonorrheal, 158. See also Con- 
junctivitis, purulent. 
lymphatica. See Conjunctivitis, 

phlyctenular. 
phlyctenular, 186 

associated pathological condi- 
tions in, 192 

catarrhal type of, 187 

consequences of, 187 

diagnosis of, 187 



528 



INDEX. 



Conjunctivitis, phlyctenular, etiologv 
of, 1 88 
pathology of, 1S6 
symptoms of. 1S6 
treatment of, 1S9 
purulent. 158 

bacteriology of, 15S. 162 
Buller's shield in, 165 
consequences of, 160 
etiology of. 155 
prognosis in, 160 
prophylaxis in, 167 
symptoms of. : ; v 
treatment of. 161 
toxic, 48. 5c. ig2 
etiology of, 193 
symptoms of, 193 
treatment of. 193 
trachomatous. 174 
consequences of. 176 
entropion from. 177 
etiology of, 174, 178 
implication of cornea in. 174. 177 
pannus in, development of, 177 
pathology of. 174, 176 
symptoms of. 174 
treatment of. 179 
mechanical, 181 
varieties of, 154 
vernal. 183 

bulbar type of, 183 
palpebral type of, 1S4 
pathology of. 184 
significance of name, 183 
symptoms of, 1S5 
treatment of, 1S5 
varieties of. : B : 
Consecutive atrophv of optic nerve, 

381 
Constipation, habitual, aloin useful 

in. 520 
Constitutional remedies useful in 
diseases of the eye, 39 
formulae for, 5 1 6-5 20 
observations upon, 57-62 
Contusions of eye. 491 

commoner causes of severe, 493 
eyeball, how protected against, 

injuries that may result from, 

491. 492. 493 
myopic eyes most apt to suffer 

from. 407. 492 
rupture of eyeball from, 491 
sympathetic ophthalmitis from, 

' 493 

traumatic cataract from, 492 
treatment of, 493, 494 
why so seldom disastrous. 401 



Convergence center, lesions of. in 

associated ocular paralyses. 446 
Convergent concomitant squint. 453 
Copper citrate in trachomatous con- 
junctivitis, 1S2 
sulphate in trachomatous conjunc- 
tivitis. 1 So. 1S1. 515 
Cornea, abscess and ulcer of. 207 
bacteriology of. 210 
carbolic acid in treatment of, 

2I 3 
clinical history of. 207, 209 
diagnosis of. 2 : B 
etiology of, 208. 210 
malignancy of. factors which 

determine, 210 
pathology of. 207, 210 
symptoms of. : : B 
treatment of. 211, 221 
varieties of. 211 
and sclera, diseases of, 202 
anatomy of, 204 
anesthesia of. in glaucoma. 277 
in neuropathic keratitis, 217, 

; : 8, 220 
method of determining, $5. 277 
conical. See Conical cornea. 
diseases of. 202 
dots on, in uveitis. 252 
eczema of, 186 

inflammation of. See Keratitis. 
leucoma of, 236 

lodgment of foreign bodies on, 487, 
4SS 
' loss of transparency of, in glau- 
coma. 277 
macula of, 236 
massage of. 231 
nebula of. 236 
opacities of. 235 
leucomatous, 236 
macular, 236 
nebular, 236 
opacity of, senile, 235 
penetrating wounds of, 494. See 
also Wounds of eye, pene- 
trating. 
anterior synechia from, 494 
impairment of vision from, 

494 
sensibility of. how determined. 277 
staphyloma of. See Staph.' 

o; cornea. 
superficial injuries of. 485 
tattooing of. 238 
tumors of. 242 
ulcer of. 207 

dendritic, 211, 220 

herpetic, 211, 220 



INDEX. 



5^9 



Cornea, ulcer of, hypopyon, 2 1 1 

'"infected." 210 
marginal, or ring. 211 
mycotic. 2 1 1 
neuropathic. 217 
phlyctenular, 2 
post-malarial. 2;c 
progressive. 200 
regressive, 209 
serpent, 211 
simple, 210 > 
C rede's prophylactic measures. 167 
Croupous conjunctivitis. 168 
Crystalline lens, anatomy and phys- 
iology of. 205 
an epithelial structure. 295 
changes in, from advancing age, 

206 
characteristics of, in early life, 

295 
development of nucleus of, 296 
diseases of. 295 
. dislocation of. See Dislocation 
of crystalline lens. 
growth of. 295 
nutrition of. 297 
transparency of. impaired by 
malnutrition. 297 
Curet, chalazion. 75 

use of, in corneal abscess, 215 
in corneal ulcers, 214 
in periostitis of orbit, 113 
Curettage. 113. 214 
CycUtis." 268 
etiology of. 26S 
impairment of vision in. 268 
plastic, 268 

oftenest due to syphilis, 268 
sympathetic ophthalmitis worst 

type of. 2 68 
treatment of. 269 
purulent, 268 
infection in, 268 
treatment of, 269 
serous. 268. See also Iritis, serous. 
symptoms of. 2 68 
treatment of. 269 
usually associated with iritis.- 268 
Cycloplegia. post-diphtheritic. 431 
Cyst, hydatid, of orbit, 114 

sebaceous, of lid. See Milium. 

of orbit, 1 1 4 
tarsal. See Chalazion. 
water}-, of lid. See Hydrocy stoma. 



Dacryoadenttis. 119 
acute, 119 

diagnosis of, 119 

34 



Da< ryoadenitis, acute, etiology of, 
119 
mistaken for cellulitis of orbit, 

119 
symptoms of. 1 19 
treatment of, 120 
chronic, 1 ig 

symptoms of, 120 
treatment of, 120 
Dacryocystitis. 131 
acute 

chronic. 132 
etiology of. 131 
in new-born, 150 

prognosis favorable in, 150 
treatment of, 150 
symptoms of. 132 
treatment of. 136 
usually dependent upon stricture 
of nasal duct. 131 
Dacryoliths. 122 
in canaliculi. 131 
treatment of, 131 
Dacryops. 121 
etiology of. 121 
Graefe's operation for, 122 
treatment of, 121 
Davlight, inspection of eye by, 34 
''Dead" teeth. 222 
Dendritic keratitis, 220 
Dental irritation, reflex, keratitis 
and paralysis of accommodation 
from, 222, 22T, 
Descending optic neuritis. 372 
Detachment of retina, 360. See also 

Retina, detachment of. 
Determination of acuteness of vision, 

27 

of corneal sensibility, 35, 277 

of intraocular tension, 23 

of visual field. 29 
Diabetes. 248. 302, 318, 339, 349, 

37 2 - 379- 3^2_ _ 
Diabetic retinitis. See Retinitis. 

diabetic. 
Diagnosis, helpful questions to be 
asked in endeavoring to reach a, 

3i 

importance of an early, in eye dis- 
eases. 40 
Diagnostic significance of symptoms 

observed in ocular inflammations, 

31 

Diagnosticating diseases of the eye, 
difficulties with which the general 
practitioner has to contend in, 17 

Dionin. 52 

formula for collyrium of, 509 
in glaucoma, 52, 289 



530 



INDEX. 



Dionin in iritis, 52, 261 

in keratitis, 52, 213 

in opacities of the cornea, 52 
Diphtheria, 169, 170, 171, 430, 445 

antitoxin, 61, 172 
Diphtheritic conjunctivitis, 169 
Diplococcus of Sattler, 174 
Diplopia, crossed, 444 

homonymous, 444 

in concomitant squint, 448, 449, 
450, 451, 453- 454, 464 

in heterophoria, 467 

in paralytic squint, 439, 441, 443, 

444, 445 
monocular, in incipient cataract, 

3°7 
of sudden onset, significance of, 

33 
Discharge from eye, character and 

amount of, diagnostic value of, 36 
Discission of cataract, 314. See 

also Cataract, general, treatment 

°t- 

Diseases of the eye, value of constitu- 
tional remedies in, 38 

Dislocation of crystalline lens, 327 
acquired, 328 

beneath the conjunctiva, 328 
congenital, 328 
consequences of, 328, 332 
diagnosis of, 330, 331 
effect upon vision of, 328, 329 
etiology of, 328 
in high myopia, 328 
interesting case of, 329 
into the anterior chamber, 

3 2 7, 33 1 
iridodonesis a symptom of, 

33 1 
traumatic, 328, 332 
treatment of, 331, 332 
varieties of, 327, 328 
of lacrimal gland, 122 
Donders on the etiology of conver- 
gent squint, 397, 453 ' 
Duboisin, 48 

Dyspepsia, induced bv eve-strain, 
418 



Ectropion, 88, 481 
cicatricial, 89 
epiphora a common svmptom of, 

88 
etiology of, 88 

from chronic conjunctivitis, 91 
from facial paralysis, 88 
often induced by lacrimal disease, 



Ectropion, organic, 89 

Arlt's operation for, 95 
commonlv of traumatic origin, 

89 
etiology of, 89 
operative treatment of, 95 
employment of Thiersch and 
Wolfe grafts in, 97 
senile, 88 

treatment of, 91, 02 
spasmodic, 88 

comparable to paraphimosis, 89 
etiology of, 88 
Snellen's operation for, 92 
treatment of, 92 
varieties of, 88 
Eczema conjunctivae, 186 
of eyelids, 71 
etiology of, 71 
treatment of, 71, 72 
Edema of conjunctiva induced by 
dionin, 52 
of lids in purulent conjunctivitis, 

163 
of retina in miliary choroido-reti- 
nitis, 344 
Electrolysis in treatment of lacrimal 

stricture, 149 
Electro-magnet, Sweet's, 499 
Embolism of central arterv of retina, 

357 

consequences of, 357 
etiology of, 357 
ophthalmoscopic picture of, 

357 
thrombotic obstruction mis- 
taken for, 357 
treatment of, 358 
Emmetropia, 393 
definition of, 393 

vision not necessarily acute in, 393 
Entogenous infection of eye after cat- 
aract extraction, 316 
Entropion, 80 

from diphtheritic conjunctivitis, 

171 
from trachomatous conjunctivitis, 

177, 182 
from trauma, 482 
of lower lid, 82 

treatment of, 82 

with caustic potash, 82 
of upper lid, operation for, 84 
organic, 81 
etiology of, 81 
Green's operation for, 86 
Hotz's operation for, 86 
treatment of, 81 
senile, 81 



INDEX. 



531 



Entropion, spasmodic, 81 
etiology of, Si 
treatment of, 82 
varieties of, So 
Enucleation of eyeball, 269, 204 
after-treatment of, 273 
Bader's scleral forceps in, 270, 

272 
control of hemorrhage in, 273 
general anesthesia required in, 

270 
instruments needed in, 270 
objectionable practices in con- 
nection with, 273 
steps of operation of, 272 
whenpanophthalmitis is present, 
269, 334 
Epilation forceps, 183 
Epiphora a characteristic symptom 
of disease of the lacrimal drain- 
age apparatus, 126 
of long standing, significance of, 32 
Episcleritis, 244 
diagnosis of, 244 
etiology of, 244 
pathology of, 244 
symptoms of, 244 
treatment of, 245 
Epithelioma of lid, 79 
Ergot, 337 

Erysipelas, facial, a cause of throm- 
bosis of central retinal vein, 359 
dacryocystitis mistaken for, 133 
Eserin, 49 

and boracic acid collyrium, for- 
mula for, 508 
follicular conjunctivitis from pro- 
longed use of, 50 
in ulcerative keratitis, 213 
precautions necessary in use of, 49 
production of iritis from injudi- 
cious use of, 49 
rules for employment of, in glau- 
coma, 49 
value of, in glaucoma, 288, 293 
Esophoria, 473 

detection and measurement of, 469, 

47°, 474 

etiology of, 396, 473, 475 

state of refraction to be determin- 
ed in ever}- case of, 474 

symptoms of, 466, 467 

treatment of, 470, 471, 474 
by glasses, 474, 475 
by operation. 475, 476, 477 
Euphthalmin hydrochlorate, 47 
formula for collyrium of, 510 
in diagnosis of cataract, 305 
of iritis, 247 



Eversion of lacrimal puncta, 128 

of lower lid, 22 

of upper lid, 22 
Examination of eyes of unruly chil- 
dren, 57 
Exanthematous fevers, 139,192,208, 

408 
Excision of chalazion, absurdity of 
attempting, 75 

of lacrimal gland, 124, 149 
sac, 149 

of orbital growths, 116 
j "Exciting eye," 256, 257 
Exophoria, 471 

detection and measurement of, 469, 

47o 
etiology of, 407, 408, 438, 467, 468, 

47i ' 
symptoms of, 466, 467 
treatment of, 470, 471, 472, 476, 

477 
by glasses, 472 
by operation, 472 
Exophthalmos from hypertrophy of 
lacrimal gland, 123 
from ophthalmoplegia totalis, 445 
from tumors of lacrimal gland, 

12 S 
of orbit, 114 
in cellulitis of orbit, 108, 109 
in periostitis of orbit, in 
i External recti muscles, insufficiency 
of. See Esophoria. 
rectus muscle, paralysis of. See 
Paralysis of external rectus 
muscle. 
1 Extraction of cataract. See Cata- 
ract, general, treatment of. 
\ Eye, ametropic, 394 
artificial, 273 

circulation of lymph in, 281 
emmetropic, 393 
exciting, 256, 257 
infection of, 316, 317, 319, 494, 

495, 497 
injuries of, 480 
inspection of, by daylight, 34 

by oblique illumination, 36 
speculum, 457 

squinting, amblyopia of, 449 
sympathizing, 257 
Eyeball, contusions of, 491 

foreign bodies in. See Wounds of 

eye complicated by lodgment of 

foreign bodies within ball. 
gunshot wounds of, 498 
penetrating wounds of, 494 
protrusion of. See Exophthal- 



532 



NDEX. 



Eye-dropper, right, and wrong, way 
to hold, 42 
suggestions regarding use of, 41, 

transference of infectious mate- 
rial by, 41 
Eyelid, epithelioma of, 79 
eversion of, 22 
malignant tumors of, 79 
sarcoma of, 80 
warts upon, 78 
Eyelids, anatomy of, 68 
diseases of, 63 
injuries of, 480 
Eye-strain a factor in causation of 
blepharitis, 64, 389 
of cataract, 303, 344, 389 
of choroido-retinitis, 343, 389 
of chronic conjunctivitis, 157, 

389 
of glaucoma, 285, 290, 344, 

389 
of headache. 390 
of indigestion, 390 
of insomnia, 390 
of nausea, 390 
of neurasthenia, 390 
of somnolency, 390 
of styes, 69 

of tinnitus aurium, 390 
of vertigo, 390 
constitutional disorders due to, 

389 
etiological importance of, 389 
ocular maladies caused by, 389, 

390 
symptoms indicative of, 32 



Facial erysipelas, 133, 359 

nerve, paralysis of. See Paralysis 
0} facial nerve. 
Far-sightedness. See Hypermetro- 

pia. 
Fellow-eye in diphtheritic conjunc- 
tivitis, 173 
in glaucoma, 290 
in purulent conjunctivitis, 165, 

166 
in sympathetic ophthalmitis, 257 
Fevers, exanthematous, 139, 192, 

208, 408 
Field of vision, contraction of, in 
detachment of retina, 363 
in embolism of retinal artery, 

357 
in glaucoma, 279, 287, 291 
in primary atrophy of optic 

nerve, 379 



Field of vision, contraction of, in 
retinitis pigmentosa, 355 
determination of, 29, 30 
in hemianopsia, 383, 384, 385, 

386 
simple method of measuring, 29 
Filtration angle of anterior chamber, 

283 
obstruction of, in glaucoma. 283, 
284 
Fistula, lacrimal, 134, 148 

of lacrimal gland, 120 
Fixation, binocular, disinclination to, 
observed in some cases of 
squint, 456 
the ideal result aimed at in oper- 
ating for squint, 456 
Fixing eye, determination of, in 

squint, 452 
Florence flask for sterilizing collvria, 

504 
Fluidity of the vitreous humor, 334 
Follicular conjunctivitis, 173 

induced by atropin, 48 

induced by eserin, 50 
Foreign bodies in anterior chamber, 

5o3 
in iris, 500 
in lens, 498 
in orbit, 504 

in vitreous chamber, 500 
superficial lodgment of, in eve, 
486 
means of detecting 489 
misconceptions of pa- 
tient in regard to, 489 
occupations which pre- 
dispose to. 4S7 
symptoms which point 

to, 32, 489 
treatment of, 490, 491 
within the eyeball. See Wounds 
0} eye complicated by lodgment 
of foreign bodies within ball. 
Formulas for agents for exact appli- 
cation to eye and lids, 514. 515 
for collvria, 505, 506, 507, 508., 509, 

510, '511 
for constitutional remedies useful 
in eye diseases, 516, 517, 518, 

5*9. 5*0 

for lotions, 511, 512 
for ointments, 513, 514 
Forster's operation, 313, 325 
Fourth nerve, paralysis of. See 
Paralysis of superior oblique mus- 
cle. 
Fowler's solution in herpes zoster 
ophthalmicus, 266 



INDEX. 



:>:>:> 



Fuchs on identity of herpes comeae 
febrilis and keratitis dendritica, 

on pathology of pinguecul: 

of pterygium, 197 

of vernal conjunct; 
Fulminating glaucoma, 286 
Fungous growth in dendritic kera- 

5, 211 

Fungus hematodes ocuh. See Ret- 
ina, glioma 



Galvanism in acquired ptosis, 100 
-etinitis pigmentosa. : 5 - 
of little value in primary atrophy 
of optic nerve, 381 
Galva no-cautery. 14c 215 

-rrian ganglion, 208 
Gilford's use of sodium salicylate in 

sympathetic ophthalmitis. 265 
Gland, lacrimal. See Lai 

gland. 
Glands of eyelid. 68 
Glasses, action of, in ametropia, 
.392 
bifocal, 421. 430 

in presbyopia. 429, 430 
in subnormal accommodative 
power. 436 
cylindrical, 419 
do not " weaken sight. "391 
effect of. in astigmatism, 419, 420 
in hypermetropia, 396, 399, 400, 

_: : _: : 
in myopia, 406. 408, 410 
not even- eye needing their help 

:' ' : : 
not given solely with a view to mak- 
ing vision more acute, 391 
not to be regarded as a dernier res- 
sort. 391 
popular misconceptions regarding, 

390, 391. 392 
smoke-tinted 5 5 
sphero-cylindrical. 419, 420 
Glaucoma. 274 
fulminating, 286 
hemorrhagic. 286 
inflammatory. 276 

clinical history [ -_ - - zSo 
constitutional disorders predis- 
posing to the development of. 
i 
diagnosis erf 277 - - . 281 
duty of general practitior. 

management or - 
etiology a£ ; 281, 282 : 285 
intermittent character of. 2 - 



Glaucoma, inflammatory, narrowing 
of the visual field in, 286 
ophthalmoscopic picture of. 2 78 
sympathetic ophthalmitis 

caused by, 280 
svmptoms of, objective. : - - 

subjective. : - - 
treatment of, 287, 289 

constitutional remedies in, 

289 
correction of refractive errors 

in. 290 
dionin in, 289 
eserin in, 288 

iridectomy the sovereign rem- 
edy in. 287, 289 
of fellow-eye in, 290 
varieties of, 286 
malignant, 286, 289 
secondary. 293 
definition of, 203 
etiology- of, 293, 294 
symptoms of, 294 
treatment of, 294 
simple. 291 

diagnosis of, 291, 292 
etiology of, 291 
symptom of. 291 
treatment of, 292 
iridectomy in, 292 
non-operative, 293 
sympathectomy in, 293 
Glioma of retina. 364 
Gonococcus. 158, 162 
Gonorrhea a cause of dacryoadenitis, 

119 
Gonorrheal conjunctivitis. See Con- 
junctivitis, purulent. 
iritis, 248 

ophthalmia. See Conjunct:- :::;. 
purulent. 
Gout in etiology of dacryoadenitis, 
119 
of eczema of lids, 71 
of glaucoma, 285, 291, 293 
of iritis, :_ v 251, 266 
of retinitis. 349 
of retrobulbar neu ritis, $74 
of scleritis. : _ ; 
Gouty affections of eye, lithia water 

in. 519 
Graduated tenotomies, no room for, 

476 
Graefe's. von, operation for dacrv- 
ops. 122 
vertical diplopia test. 4^4, 469 
Grandmont's, de, operation for pto- 
102 



534 



NDEX. 



Granular conjunctivitis. See Con- 
junctivitis, trachomatous. 

lids. See Conjunctivitis, tracho- 
matous. 
Green's operation for entropion, 86 
"Ground-glass" cornea, 223 
Gruening's operation for ptosis, 102 
Gummata in lacrimal sac and nasal 

duct, 139 
Gummatous iritis, 255 
Gunshot-wounds of eye, 498 



Halsted's use of silver foil as a sur- 
gical dressing, 96 
Head and Campbell's investigation 
of pathology of herpes zoster, 259 
Headache in ametropia, 32, 390, 398 
in astigmatism, 418 
in choked disc, 371 
in latent muscular anomalies, 431, 

467 
in toxic amblyopia, 375 
Helmholtz's theory of accommoda- 
tion, 426 
Hemianopsia, 383 
binasal, 384 
bitemporal, 385 

etiology of, 383, 386 
localizing value of, 387 
prognosis in, 386 
symptoms of, 383 
treatment of, 387 
etiology of, 383, 385 
explanation of, 383 
homonymous lateral, 385 

central vision retained in, 385 
etiology of, 385 
pathology of, 385 
symptoms of, 385, 386 
transient type of, 386 
treatment of, 387 
without localizing value 386 
horizontal, 384 
symptoms of, 383 
varieties of, 383, 384 
Hemiopia. See Hemianopsia. 
Hemorrhage into \itreous humor, 
336 
subconjunctival 193 
Hemorrhagic glaucoma, 286 
Hernia of ciliary body, 494 
of iris, 494 

of lacrimal gland. See Lacrimal 
gland, dislocation of. 
Herpes corneae febrilis, 220 
zoster ophthalmicus, 218, 259 
etiology of, 218 
impairment of vision from, 218 



Herpes zoster ophthalmicus, iris 
often involved in, 218 
symptoms of, 218 
treatment of, 221 
Heterophoria, 466, 467, 469, 470, 
477. See also Muscular anom- 
alies of the eyes, latent. 
Holden, Ward, 378 
Holocain, action of, in promoting 
healing of corneal ulcers, 213 
formulae for collyria of, 507, 511 
in corneal ulcers, 181, 212, 213 
indications for use of, 507 
in episcleritis, 245 
in keratomalacia, 216 
in neuropathic keratitis, 221 
Homatropin hvdrobromate, 47 
formula for colly rium of, 510 
in diagnosis of cataract, 304, 305 
of iritis, 247 
Hordeolum, 67 
etiology of, 67, 69 
symptoms of, 67 
treatment of, 69, 70, 71 
abortive, 69 
Hot water, 512 

in interstitial keratitis, 229 
in iritis, 262 

in purulent conjunctivitis, 163 
Hotz's operation for entropion, 86 
Hutchinson, Jonathan, 223 

teeth, 227 
Hyoscyamin hvdrobromate, 48, 436 

formula for colly rium of, 509 
Hyperemia, diagnostic significance 
of the different types of bulbar, 

35 

of conjunctiva, 152 
acute, 153 
chronic, 153 
etiology of, 153 
treatment of, 153 
Hypermetropia, 394 

absolute, 395 

axial, 397 

commonly of congenital origin, 395 

consequences of, 396, 398, 399, 
401, 402 

correction of convergent squint in, 
402 

curvature, 397 

definition of, 395, 397 

disturbed relation of accommoda- 
tion and convergence in, 396, 
402 

factors which influence develop- 
ment of squint in, 397 

how acquired, 397 

influence of glasses in, 396, 399,402 



NDEX. 



535 



Hypermetropia, manifest, 401 

most prevalent type of ametropia, 

395 

non-facultative, 395, 398 

not a pathological condition, 397 

often complicated by astigmatism, 

403 
often inherited, 398 
presbyopia influenced by, 401 
relation of convergent squint to, 

397> 402 
rules for prescription of glasses in, 

399, 400, 401, 402 
tension of accommodation in, 395, 

39 6 

treatment of, 399, 400, 401, 402, 
403 

varieties of, 395, 397, 401 
Hyperopia. See Hypermetropia. 
Hyperphoria, 477 

definition of, 477 

detection and measurement of, 478 

etiology of, 477 

ill consequences of, 477, 478 

treatment of, 478, 479 
Hypertrophy of lacrimal gland, 123 
Hypochyma, 298 
Hypopyon in iritis, 255 

ulcer of cornea, 211 



Ice-cloths, 41, 154, 512 

in purulent conjunctivitis, 163 
Iced water, 41, 512 
Illumination, oblique. See Oblique 

illumination. 
Imbalance, muscular, 468 
Incised wounds of cornea, 494 

of lids, 482 
Incubation period, indefinite, in 
sympathetic ophthalmitis, 257 
in purulent conjunctivitis, 159 
Indigestion, 279 

induced by eye-strain, 390, 467 
Infection of eye, after cataract ex- 
traction, 316, 317, 319 
from penetrating wounds, 494, 

495> 497 
Injuries of bulbar conjunctiva, 483 
consequences of, 483 
from caustic agents, 483 
symblepharon from, 483 
treatment of, 483, 484, 485 
of cornea, superficial, 485 
consequences of, 485 
from caustic agents, 485 
treatment of, 485, 486 

when wound is infected, 486 
of eye and its appendages, 480 



Injuries of eyelids, 480 

anchvloblepharon from, 480, 

482,483 
ectropion from, 481 
from gunpowder, 483 
malposition of the lacrimal 

puncta from, 480 
symblepharon from, 480, 482 
treatment of, 482, 483 
Thiersch grafts in, 483 
Insomnia induced by eye-strain, 390, 

418, 467 
Inspection of eye by daylight, 34 
Insufficiency of external recti mus- 
cles, 473. See also Esophoria. 
of internal recti muscles, 471. 
See also Exophoria. 
Internal recti muscles, insufficiency 

of. See Exophoria. 
Interstitial keratitis. See Keratitis, 

interstitial. 
Intraocular lymph-stream, 282 
tension, determination of, 23 
how noted, 24 
Inunctions of mercurial ointment, 58 
Inversion of lacrimal puncta, 128 

of lid, 80 
Iodin, tincture of, application of, to 
corneal ulcers, 51 
ointment, 124 
Iridectomy, 161, 238, 240, 241, 266, 
267 
extraction of cataract with, 315 
in glaucoma. 49, 287, 289, 292, 294 
in partial cataract, 325 
in zonular cataract, 326 
preliminary to extraction of cata- 
ract, 3 13 
Iridocyclitis, 256, 268 
Iridodialysis, 491 
Iridodonesis, 331 

Iris and ciliary body, diseases of, 246 
diseases of, 246 
hernia of, 494 
wounds of, 494, 495, 498 
Iritis, 246 

a common cause of blindness, 246 
character of vascular injection in, 

247 
consequences of neglected, 250, 

267 
diagnosis of, 246 
diagnostic value of mydriatic in, 

247 
etiology of, 248 
excited by injudicious use of eserin, 

49 
general management of patient in, 
266 



53^ 



INDEX 



Iritis, gonorrheal, 248 
hypopyon in, 255 
involvement of deeper eye struc- 
tures in, 250 
iridectomy in, 266, 267 
myotics contraindicated in, 50 
neuropathic. See Iritis, trophic 

nerve. 
of herpes zoster ophthalmicus, 2 18, 

259 
oftenest dependent upon syphilis, 

2 55 
plastic, 250, 253 

characteristics of, 250 

chronic, 260 

etiology of, 251 

iridectomy in, 267 

treatment of, 260, 261 

types of posterior synechia in, 

254 

varieties of, 251 
purulent, 252 

etiology of, 252 

treatment of, 260, 265 
serious consequences of failure to 

recognize, 246 
serous (uveitis), 252 

characteristics of, 252 

disposition to increased intra- 
ocular tension in, 252 

etiology of, 252 

marked impairment of vision in, 

253 
treatment of, 264, 265, 266 
spongy, 259 
sympathetic, 256 

bacteria probably play no part 

in etiology of, 258 
character of posterior synechia 

in, 258 
clinical history of, 257, 258 
consequences of, 258 
etiology of, 256, 258, 259 
"incubation period" indefinite 

in, 257 
malignancy of, 258 
ophthalmitis from neglected, 

250 
probably neuropathic in origin, 

2 5 8 
removal of exciting eye in, 264 

resemblance of, to iritis of 

herpes zoster ophthalmicus, 

259 

symptoms of, 258 

treatment of, 260, 264 
mercury in, 264 
sodium salicylate in, 265 
symptoms of, 246, 247 



Iritis, syphilitic, 254 
condylomatosa, 255 
diagnosis of, 255 
gummosa, 255 
met with in inherited syphilis, 

255 
occurs as a prenatal affection, 

255 
occurs oftenest in secondary 

stage of disease, 253 
symptoms of, 254 
treatment of, 260, 262, 263, 264 
treatment of, 260 
"trophic" nerve, 248 

character of posterior syne- 
chia in, 249, 254, 259 
characteristics of, 249 
etiology of, 248, 259 
formation of anterior syne- 
chia in, 254 
herpes zoster ophthalmicus 

a variety of, 259 
sympathetic ophthalmitis a 

variety of, 259 
varieties of, 248, 259 
varieties of, 250 
Iron chlorid in interstitial keratitis, 
230 
in retinitis albuminuria, 351 
iodid, 517 

in blepharitis of strumous origin, 

67 
in interstitial keratitis, 230 
in periostitis of orbit, 112 
in phlyctenular conjunctivitis, 

191 
in scleritis, 245 
in strumous affections of the eye, 

60 
Irritation, sympathetic, 257 



Jaeger's test types, 28 
Japanese stove, 41 
Tequirity, 183 
Juvenile cataract, 298 



Keratitis, 202 

bacteriology of, 204 

consequences of, 203 

dendritic, 220 

etiology of, 203 

from reflex dental irritation, 222 

herpetic, 220 

impairment of vision from, 203 

interstitial, 223 

a disease of childhood, 225 



INDEX. 



537 



Keratitis, interstitial, always depen- 
dent upon inherited syphilis, 

2 2 7, 

chronicity a marked feature of, 

225 
diagnostic signs of, 224 



etiology of, 



of 



ground-glass appearance 
cornea in, 223 

Hutchinson teeth often associ- 
ated with, 227 

iritis in conjunction with, 226 

marked impairment of vision in, 
226 

pathology of, 224 

recurrent attacks of, not rare, 226 

symptoms of, 223 

treatment of, 227 

neuropathic, 216 

anesthesia of cornea in, 217 

disturbance of metabolism of 
cornea a prime factor in caus- 
ation of, 217 

etiology of, 217, 222 

gasserian ganglion in, 216 

milder forms of, 218 

anesthesia of cornea in, 219 
clinical characteristics of, 

2I 9. 
etiology of, 219 
malarial fever a factor in 

causation of, 220 
ophthalmic ganglion in, 219 
symptoms of, 219 
treatment of, 221 
usually unilateral, 220 
varieties of. 218 
ophthalmic ganglion in, 217 
treatment of, 221 
varieties of, 216 
pannitic, 231 

canthotomy in, 233 
diagnosis of, 233 
etiology of. 231 
treatment of, 233 
phlyctenular, 205 
etiology of, 188 

impairment of vision from, 205 
symptoms of, 205 
treatment of, 189, 206 
post-malarial, 220 
suppurative, 204 
. bacteriology of, 204 
etiology of, 204 

factors which determine tracta- 
bility or intractability of, 204 
symptoms of, 202 
"trophic nerve." See Keratitis, 
neuropathic. 



Keratitis, ulcerative, 207 

varieties of, 207 
Keratoconus. See Conical cornea. 
Keratomalacia, 215 

etiology of, 215 

malignancy of, 216 

night-blindness a premonitory 
symptom of, 216 

symptoms of, 216 

treatment of, 216 
Kerato-scleritis, 242 
Klebs-Loffler bacillus, 170, 171, 211 
Knapp's operation for anterior staph- 
yloma, 241 

roller-forceps, 118 

Lacrimal apparatus, diseases of, 1 18 
drainage apparatus, 125 
duct. See Nasal duct. 
fistula, 134, 148 
etiology of, 134 
treatment of, 148 
gland, anatomy of, 121 
atrophy of, 124 
diseases of, 119 
dislocation of, 122 
excision of, 149 
fistula of, 120 
hypertrophy of, 123 

exophthalmos from, 123 
treatment of, 124 
Velpeau's operation for, 124 
inflammation of. See Dacryo- 

adenitis. 
tumors of, 125 
symptoms of, 125 
treatment of, 125 
varieties of, 125 
probe, author's, for use by patient, 
149 
supplementary, 145 
introduction of, 144 
probes, author's, 141 
puncta, atresia of, 126 
etiology of, 127 
treatment of, 127 
eversion of, 128 
inversion of, 128 
malpositions of, 128 
treatment of, 128 
sac, abscess of. See Dacryocys- 
titis. 
blennorrhea of, 132 
etiology of, 132 
symptoms of, 132 
destruction of, 149 
excision of, 149 
gummata of, 139 



538 



INDEX. 



Lacrimal sac, inflammation of, 132. 
See also Dacryocystitis. 
primary inflammation of, 131 
stricture. See Stricture of nasal 
duct. 
Lamellar cataract. See Cataract, 

zonular. 
Latent muscular anomalies, 466 
Lateral illumination. See Oblique 

illumination. 
Lead acetate, opacities of cornea 

from, 237 
Leber, 222 

Leeches in acute dacryoadenitis, 120 
Lens, crystalline. See Crystalline 
lens. 
dislocation of. See Dislocation 

of crystalline lens. 
foreign bodies in, 498 
"trituration" of, 313 
wounds of, 303, 494, 498 
Lenses, bifocal, 430 
cylindrical, 419 
spherical, 390 
types of, 390 
Leucocythemic retinitis, 352 
Leucoma, 187, 236 
adherens, 236 
with anterior synechia, 236 
Leucomata, 236 

Light not the reprehensible thing it 
was once supposed to be, 54 
perception, definition of, 28 
protection of inflamed eyes from 
undue exposure to, 54 
Lithia water, 519 

Local remedies useful in diseases of 
the eye, 39 
formulas for, 505-515 
observations upon, 39-57 
Locomotor ataxia, 441 
Lotion of belladonna, formula for, 
512 
in iritis, 262 
"of opium and boracic acid, " for- 
mula for, 512 
in cellulitis of orbit, 109 
in corneal ulcers, 213 
in dacryocystitis, 136 
in glaucoma, 288, 294 
in iritis, 262 
in miliar}- choroido-retinitis, 

348, 433 
in myopia, 346, 412 
in panophthalmitis, 334 
in scleritis, 245 
in traumatic lesions of eye, 
346, 466, 493, 496, 502 
"Lotions," formulae for, 511, 512 



Lower lid, ectropion of, induced by 
lacrimal disease, 89 
operation for entropion of, 82 
Luxation of lens. See Dislocation 

of crystalline lens. 
Lymph-spaces of eye, 282, 283 
Lymph-s.ream of eye, 281, 282, 283 
increase of, in glaucoma, 284 



Macula lutea, 344 

Maculae of cornea, 236 

Macular region, 407 

Maddox-rod, 469, 470, 478 

Magnet, Sweet's, 499 

Malarial fever, keratitis induced by, 

220 
"Malignant" glaucoma, 286, 289 
tumors of choroid, 348 

of ciliary body, 269 

of lacrimal gland, 125 

of lid, 79 

of orbit, 114 

of retina, 364 
Maturity of cataract, 308, 309 
Meibomian glands, 68 
Membranous conjunctivitis, 168 
Meningitis basilar, 372 

in causation of optic neuritis, 371, 

37 2 
tuberculous, 371 
Mercurial inunctions, 263, 264, 353 
Mercury, administration of, in eye 
diseases, 58 
bichlorid, 50, 51 

addition of sodium chlorid to 

collyria of, 51 
as nasal spray in treatment of 

stricture of nasal duct, 148 
formula for collyrium of, with 

sodii chlorid, 506 
formulae for solutions of, 511, 

512 
in blennorrhea of lacrimal sac, 

137 
in croupous conjunctivitis, 169 
in diphtheritic conjunctivitis, 

172 
in follicular conjunctivitis, 173 
in penetrating wounds of eyeball, 

495 
in stricture of nasal duct, 148 
internally, with tincture iron, in 

interstitial keratitis, 230, 518 
in vernal conjunctivitis, 185 
in wounds of eyelids, 482 
contraindicated in suppuration 
and ulceration of cornea, 58, 
212 



NDEX 



539 



Mercury in acquired ptosis, ioo 
in choroiditis, 345 
in choroido-retinitis, 310 
in chronic dacryoadenitis, 120 
in cyclitis, 269 
indications for administration of, 

5*7- 5 l8 
in diseases of the eye, 57 
in herpes zoster ophthalmicus, 263 
in interstitial keratitis, 229, 230 
in iritis, 262, 263 
in optic neuritis, 373 
in paralysis of third nerve, 446 
in periostitis of orbit, 112 
in retrobulbar optic neuritis, 375 
in secondary glaucoma, 294 
in sympathetic ophthalmitis, 264 
in syphilitic orbital growths, 117 

retinitis, 353 

tarsitis, 80 
yellow oxid, formulae for ointments 

of. 5i3 
in blepharitis, 54, 65 
in chalazion, 74 
in corneal opacities, 238 

ulcers, 212 
in eczema of lids, 71, 190 
in hordeolum, 69, 70 
in phlyctenular conjunctivitis, 

189' 
in vernal conjunctivitis, 185 
of no value in interstitial 
keratitis, 229 
Metallic foreign bodies, 497, 502, 504 
Miliary choroido-retinitis, 303, 343 
Milium, 77 

treatment of, 77 
Moist heat, method of applying, to 

eye, 41 
Monocular blindness, individuals 
not rarely unaware of existence of, 

33 
Mucocele, 132 
Mumps, 119 
Murdoch's eye-speculum, 457, 458 

protective shield, 317 
Muscae volitantes, 335 

more numerous and conspicu- 
ous in ametropic eyes, 336 
popular misconceptions as to 

significance of, 335 
present in all eyes, 335 
Muscle-balance, determination of, 
469 
Maddox-rod in, 469 
Schild's pin-hole light in, 470 
in correction of hypermetropia, 
401 
of myopia, 410 



Muscle-balance in subnormal accom- 
modative power, d.34, 435, 436 
Muscular anomalies of the eyes, 
438 
actual, 467, 468 
apparent, 467, 468 
dependent upon refractive 

errors, 438 
etiology of, 438 
latent, 438, 439, 466 

asthenopia, how caused by, 

439> 467 

consequences of, 439, 466, 
467 

contradictory views regard- 
ing etiology of, 467, 468 

correction of, 470, 471 
by glasses, 470, 471 
by operation, 470, 471, 

47°> 477 
determination of, 469, 470 
etiology of, 467, 468 
heterophoria a synonym of, 

466 
influence of refractive 

errors upon, 467, 468 
multiple Maddox-rod in 

measurement of, 469 
ocular disturbances from, 

467 
Schild's pin-hole light in 

measurement of, 470, 478 
treatment of, 470, 471 
varieties of, 467, 468 
whether apparent or actual, 

how determined, 468 
manifest, 438, 439, 440 

comprise all the varieties of 

squint, 438 
not in themselves provoca- 
tive of asthenopia, 439 
oftenest due to refractive 

errors, 438, 439 
only exceptionally due 

solely to muscular faults, 

43 8 ,'43y 
the deformity and rapidly 
developing amblyopia of 
misdirected eye most seri- 
ous consequences of, 439 
treatment of. See Squint, 

treatment of. 
when of paralytic origin, 
develop suddenly, 439 
of congenital origin, 438 
of paralytic origin, 438 
varieties of, 438, 466 
imbalance, 468 
Mycotic ulcer of cornea, 211 



540 



INDEX 



Mydriasis, accidentally induced, 431 
conditions which give rise to, 26 
disadvantages of, in measuring 

refractive errors, 422 
from application of belladonna 

plaster, 431 
from reflex dental irritation, 223 
in ophthalmoplegia interna, 445 
in paralysis of accommodation, 

43i' 

of oculomotorius. 445 
Mydriatic, value of transient, in 
searching for pathological changes I 
in eye, 37 | 

Mydriatics, indiscriminate use of, 
reprehensible in advanced life, 285 
Myopia. 403 

a pathological condition, 403 
apparent, from spasm of ciliary 

muscle, 432 
asthenopia in, 408, 409 
astigmatism a potent factor in 

causation of, 405, 406, 410 
axial 404, 405 
cataract in, 407 

caused by conical cornea, 241, 405 
choroido-retinitis in, 407 
curvature. 404 
definition of, 403, 404 
detachment of retina in, 407 
development of divergent squint 
in, 407, 408 

of posterior staphyloma in, 404 
diagnosis of, 409 

disturbed relation of accommoda- 
tion and convergence in, 407 
etiologv of, 403, 404, 40^, 406. 

408 ' 
exceptionally a consequence of 

systemic disease, 408 
exophoria in, 407, 408 
factors which influence selection 

of glasses in, 410. 411, 412 
glasses a therapeutic agent of 

great value in, 411 
influence of age upon progress of, 

407, 409 
influence of glasses in, 410, 411, 

412 
muscae volitantes common in, 409 
not excluded by ability to read at 

usual distance, 7,7, 
pathology of, 404, 405, 406, 407 
predisposition to, often inherited, 

403, 405 
removal of crvstalline lens in high, 

413 
symptoms of, 409 

tenotomy in. 413 



Myopia, treatment of, 409, 410, 411, 
412, 413 
usually an acquired fault, 403 
Myopic eyes liable to injury from 
trivial traumatisms, 407, 492 
glasses, 410 
Myosis, conditions which may give 
rise to, 26 
in spinal disease, 379 
Myotics, action of, in glaucoma, 48 
rules for employment of, 49 



Nasal disease, etiological impor- 
tance of, in causation of lacrimal 
stricture, 135, 138, 139 
duct, anatomy of, 137 

author's measurements of, 141 
stricture of, 137 
Nausea induced by eye-strain, 390, 

418, 467 
Near-sightedness. See Myopia. 
Nebulas of cornea, 236 
Necrosis of cornea, 109, 115, 160, 215 

of orbital walls, 1 1 1 
Needle for removal of foreign bodies, 
490 
operation for capsular cataract, 

3 2 7 
for juvenile cataract, 314 
Nephritis in causation of optic 
neuritis, 372 
of retinitis, 349 
Neurasthenia induced by eye-strain, 

390, 41S, 467 
Neuritis, optic. See Optic neuritis. 
Neuroepithelioma. See Retina, gli- 
oma of. 
Neuropathic iritis. See Iritis, 
" trophic" nerve. 
keratitis, 216 

milder forms of, 218 
origin of sympathetic ophthal- 
mitis, 258 
Neuro-retinitis, 370 
Night-blindness in keratomalacia, 
216 
in retinitis pigmentosa, 355 
Nitrite of amy! in embolism of cen- 
tral retinal artery, 358 
in quinin blindness, 378 
Nitroglvcerin in quinin blindness, 

378 ' 
Non-magnetic foreign bodies, 502 
Normal salt-solution, 51, 505 
Notched and pegged teeth, 227 
Noyes. H. D., and E. Williams, first 
to use large lacrimal probes, 140 



INDEX. 



541 



Nystagmus, 447 
acquired, 447 1 

commonly of congenital origin, 

447 
etiology of, 447 

minor's, 447, 448 
treatment of, 447, 448 



Oblique illumination, 19, 36, 304, 
500 
information afforded by, 36 
Ocular muscles, 440, 442 
anatomy of, 440 
associated movements of, 446 

paralyses of, 446 
insufficiency of. See Muscu- 
lar anomalies, latent. 
latent anomalies of, 446 
manifest anomalies of, 440 
nerves distributed to, 440 
operations upon, 457, 458 
paralysis of 441, 442. See also 
Squint, paralytic. 
paralyses, conjugate. See Con- 
jugate ocular paralyses. 
Oculomotorius, paralysis of. See 

Paralysis oj oculomotorius. 
Ointments, application of, to eye and 
to lids, 45 
formulae for, 513, 514 
indications for use of, 53 
"O'd-sight," 297 

Old-sightedness. See Presbyopia. 
Opacities of cornea, 235 

dionin in treatment of, 238 
etiology of, 235, 236 
from lead acetate, 237 
how distinguished from lenticu- 
lar opacities, 238 
impairment of vision from, 236 
iridectomy for, 238 
tattooing of, 239 
treatment of, 238 
varieties of, 236 
of lens. See Cataract. 
of vitreous humor, 334 
secondary capsular, 326 
Ophthalmia, granular. See Con- 
junctivitis, trachomatous. 
neonatorum, 159, 161, 163 
purulent. See Conjunctivitis, 

purulent. 
sympathetic. See Iritis, sympa- 
thetic. 
Ophthalmic ganglion, 208 
Ophthalmitis, sympathetic, 256. See 
also Iritis, sympathetic. 



Ophthalmoplegia externa, 445 

necessarily of nuclear origin. 

445 
interna, 445. See also Paralysis 
0} ciliary muscle. 
oftenest dependent upon diph- 
theria, 445 
totalis, 445 

characteristic picture of, 444, 445 
exophthalmos a symptom of. 445 
Ophthalmoscope, diagnosis of gli- 
oma of retina without aid of, 364 
ear or throat mirror as substitute 

for, 305 _ 
in diagnosis of cataract, 305 
in hands of general practitioner 
rarely trustworthy aid to diag- 
nosis, 19 
Opium and morphin in diseases of 
eye, 60 
as a local remedy in diseases of the 

eye, 53 
lotion of, formula for, 512 
mode of application of, 53 
Optic nerve, atrophy of, 378 
consecutive, 381 
diagnosis of, 381 
etiology of, 381 
ophthalmoscopic picture of, 

3§i> 38-' 
prognosis in. 382 
symptoms of, 381 
treatment of, 382 
primary, 378 

Argyll-Robertson symptom 

in. 379 
behavior of pupil in, 379 
etiology of, 378 
hereditary form of, 379 
often an early symptom of 

tabes, 380 
ophthalmoscopic picture of, 

379. 3 8 ° 
symptoms of, 379 
treatment of, 381 
unfavorable prognosis in, 

. 379- 3 8 i 
varieties of, 378 
diseases of, 367 

inflammation of. See Optic 
neuritis. 
neuritis, 367 
descending, 372 
etiology of, 372 
ophthalmoscopic picture of, 

368, 369, 372 
treatment of, 373 
etiology of, 367, 368 
intraocular. See Choked disc. 



542 



INDEX. 



Optic neuritis, ophthalmoscopic pict- 
ure of, 369 
orbital. See Optic neuritis, re- 
trobulbar. 
pathology of, 367, 368, 369 
retrobulbar, 374 
acute, 374 

etiology of, 374 
impairment of vision in, 

374 
pathology of, 374 
prognosis in, 375 
symptoms of, 374 
treatment of, 375 
chronic, 375 

etiology of, 375, 376 

more common in males, 

375 
ophthalmoscopic changes 

in, 376 
pathology of, 375 
prognosis in, 377 
symptoms of, 375, 376 
treatment of, 377 
varieties of, 367, 368 
Orbicularis muscle, anatomy of, 92 
Orbit, abscess of, 108 
benign tumors of, 114 
cellulitis of, 108 
diseases of, 107 
exenteration of, 116 
malignant tumors of, 114 
sarcoma of, 115 
tumors of, 113 
Orbital optic neuritis. See Optic 
neuritis, retrobulbar. 
walls, periostitis of, 1 1 1 
Orthophoria, 434 
Orthophoric condition, 468 
muscle-balance, 434 



"Pain-reaction" test, 500 
Palsy. See Paralysis. 
Panas's operation for ptosis, 104 
Pannitic keratitis, 231 
Pannus, 174, 177, 182, 231 
diagnosis of, 233 
etiology of, 231 
treatment of, 233 
Panophthalmitis, purulent, 240, 268, 
269, 333 
consequences of, 334 
course of, 333 
etiology of, 333 
symptoms of, 333, 334 
treatment of, 334 
Papillitis. See Choked disc. 



Paracentesis of anterior chamber, 215 
Paralyses, conjugate ocular. See 

Conjugate ocular paralyses. 
Paralysis of accommodation. See 
Paralysis oj ciliary muscle. 
and mydriasis from reflex dental 
irritation, 223 
of ciliary muscle, 430 
etiology of, 430, 431 
from application of bella- 
donna plaster, 431 
from reflex dental irritation, 

223 
often accompanied by mydri- 
asis, 431 
prognosis usually favorable 

in, 43 1 
symptoms of, 431 
treatment of, 432 
vision, how impaired in, 431 
of external rectus muscle, 442 

commonest of ocular pal- 
sies, 442 
etiology of, 443 
pathology of, 443 
prognosis favorable in, 443 
symptoms of, 443 
treatment of, 443 
usually of orbital origin, 

443' 
of facial nerve, 105 

epiphora from, 105 

etiology of, ic6 

keratitis in, 105 

symptoms of, 105 

treatment of, 106 
of fourth nerve, 444 
of oculomotorius, 444 

etiology of, 444, 445, 446 

one of the commonest ocular 
palsies, 444 

prognosis in, 446 

ptosis a usual symptom of, 

445 
symptoms of, 445 
treatment of, 446 
varieties of, 445 
of sixth nerve. See Paralysis of 

external rectus muscle. 
of superior oblique muscle, 444 
diagnosis of, 444 
etiology of, 444 
symptoms of, 444 
treatment of, 444 
of third nerve, 444 
Paralytic squint, 440. See also 

Squint, paralytic. 
Parenchymatous keratitis. See Ker- 
atitis, interstitial. 



INDEX. 



543 



Penetrating wounds of eye, 494. 
Sec also Wounds of eye, penetrat- 
ing. 

Pepsin, essence of, administered in 
conjunction with potassium iodid 
and the salicylates, to prevent 
gastric irritation, 59 

Pericorneal injection, significance of, 

35 
Perimeter, standard, 30 
Periostitis of orbital walls, III 
consequences of, 1 1 1 
etiology of, 111 
symptoms of, in 
treatment of, 112 
Permanganate of potash in diph- 
theritic conjunctivitis, 172 
Pernicious anemia, retinitis in, 352 
Persistent pupillary membrane, 320 
Phimosis, spasm of orbicularis pal- 
pebrarum from, 223 
Phlyctenular conjunctivitis. See 
Conjunctivitis, phlyctenular. 
keratitis. See Keratitis, phlycten- 
ular. 
Phosphates of iron, quinin and 
strychnin, 516 
in blepharitis marginalis, 

in phlyctenular conjunctiv- 
itis, 191 
in recurrent hordeola, 71 
value of, in diseases of the eve, 
60 
Photophobia, not a symptom of 

retinitis or neuritis, 32 
Phthisis bulbi, 496 
Physiological salt solution, 51 
Pigmentary degeneration of the 
retina, 354. See also Retinitis 
pigmentosa. 
Pilocarpin hydrochlorate, formula 
for collyrium of, 509 
in detachment of retina, 363 
in iritis, 262 
in optic neuritis, 373 
in serous iritis, 265 
internal administration of, 61, 265, 

519 
Pinguecula, 194 

diagnosis of, 195 

etiology of, 195 

origin of name, 195 

pathology of, 195 

treatment of, 195 
"Pink eye," 156 

Pituitary body, enlargement of, 386 
Plastic cyclitis. See Cyclitis, plastic. 

iritis. See Iritis, plastic. 



Pneumococcus in catarrhal conjunc- 
tivitis, 156 
in suppurative keratitis, 204, 211 
Polyopia, monocular, in incipient 

cataract, 307 
Polypus in canaliculus, 131 
Posterior polar cataract, 322 
staphyloma, 404, 406, 408 
synechia. See Synechia, poste- 
rior. 
Post-hemorrhagic blindness, etiol- 
ogy o f > 359 
Post-malarial keratitis, 220 
Post-neuritic atrophy of optic nerve. 
See Atrophy of optic nerve, con- 
secutive. 
Potassium iodid, 59, 517 
in acquired ptosis, 100 
in choroiditis, 345, 346 
in chronic dacryoadenitis, 120 
in cyclitis, 269 
in detachment of retina, 363 
in diseases of the eye, 59 
in episcleritis, 245 
in facial paralysis, 107 
in glaucoma simplex, 293 
in hemorrhage into vitreous 

chamber, 337 
in hypertrophy of lacrimal 

gland, 124 
in interstitial keratitis, 229, 230 
in iritis, 262, 263, 264, 265 
in neuropathic keratitis, 222 
in optic neuritis, 373 
in paralysis of ciliary muscle, 
432 
of external rectus, 443 
of third nerve, 446 
in periostitis of orbit, 112 
in retinitis albuminurica, 351 
in retrobulbar optic neuritis, 375 
in scleritis, 244 
in secondary glaucoma, 294 
in syphilitic orbital growths, 117 
retinitis, 353 
Prelacrimal abscess, 137 
Presbyopia, 297, 427 
advent of, 428 
a progressive condition, 429 
asthenopia from neglect of, 428 
decline of, in incipient stage of 

cataract, 302, 430 
explanation of, 427, 428 
how influenced by ametropia, 399, 

428, 429 
late development of, 428 
symptoms of, 32, 428 
treatment of, 429, 430 
bifocal lenses in, 430 



544 



NDEX. 



Presbyopia, treatment of, fallacy of 
the popular belief that little 
skill is required in selection 
of glasses in, 429 
glasses the only remedy in, 429 
Primary atrophy of optic nerve, 378 
Prismatic glasses, 471 
Prisms from trial case in measure- 
ment of heterophoria, 469 
in correction of squint, 462 
in esophoria, 475 
in exophoria, 422 
in hyperphoria, 478 
in subnormal accommodative 
power, 437 
Protargol, 51, 157, 169 
in dacryocystitis, 137 
in purulent conjunctivitis, 164, 168 
in trachomatous conjunctivitis, 
180, 181 
Pseudo-pt rygium, 197 
Pterygium, 195 
description of, 195 
etiology of, 197 

genesis of, author's theory of, 198 
impairment of vision from, 196 
operation for removal of, 199 
treatment of 198 
Ptomaine poisoning, 431 
Ptosis, 98 
acquired, 98 
etiology of, 98 
symptoms of, 98 
treatment of, 100 
Bowman's operation for, 102 
congenital, 98 

characteristic facial expression, 

in, 99 
etiology of, 98 
treatment of, 99, 101, 102, 103, 

_ 104, 105 
vicarious action of occipito- 
frontalis in, 98 
de Grandmont's operation for, 102 
Gruening's operation for, 102, 103 
Panas's operation for, 104, 105 
varieties of, 98 
Pulsation of retinal vessels, 279 
Puncta lacrimalia. See Lacrimal 

puncta. 
Pupil, 24 

Argyll Robertson, 27 
consensual reflex action of, 25 
direct reflex action of, 24 
enlargement of, in glaucoma, 277, 

291 
occlusion of, in iritis, 249, 250, 254, 

258 
Pupillary reactions, 24 



Pupils, associated action of, 25 
normal variations in size and 

activity of, 25 
size of, influenced by refractive 

state of eyes, 25 
size and reactions of, conditions 

which influence, 25 
unequal size of, in anisometropia, 

25 
Purulent choroiditis, 340. See also 
Panophthalmitis, purulent. 
conjunctivitis. See Conjunctivi- 
tis, purulent. 
cyclitis. See Cyclitis, purulent. 
iritis. See Iritis, purulent. 
panophthalmitis. See Panoph- 
thalmitis, purulent. 
Pyramidal cataract, 321 
Pyrophospate of sodium. See So- 
dium pyrophospate. 



Questions helpful in reaching a 

diagnosis, 31 
Quinin blindness, 377 

pathology of, 377, 378 

symptoms of, 377, 378 

treatment of, 378 
in neuropathic keratitis, 221 
in purulent cyclitis, 269 

iritis, 262, 265 
in suppurative keratitis, 206, 212 
value of, in abscess and ulcer of 

cornea, 60 



Randolph, R. L., 186 
Rays of light, parallel, 393 

course of, in emmetropic eye, 

393 
in hypermetropic eye, 395, 

398 
in myopic eye, 403, 404 
Reading distance, importance of 

testing muscle-balance for, 469 
Reconstruction of lid margin (Hotz) 

in entropion, 87 
Reflex dental irritation in keratitis, 
222 
paralysis of ciliary muscle 

from, 223 
spasm of orbicularis palpe- 
brarum from, 223 
Refraction, anomalies of, 388 
Refractive and muscular anomalies, 
symptoms which suggest existence 
of, 32 



INDEX. 



545 



Remedies, constitutional, useful in 

diseases of the eye, 39 

formulae for, 516-520 

observations upon, 57-62 

local, useful in diseases of the eye, 

39 
formula? for, 505-515 
observation upon, 39-57 
Retina, detachment of, 360, 491 

cataract a late complication in, 

363 
diagnosis of, 363 
etiology of, 361 
far-fetched theories of genesis 

of, 361 
in high myopia, 342, 361 
in intraocular growths, 362 
subconjunctival injection of salt 

solution in, 363 
symptoms of, 362, 363 
treatment of, 363, 364 
unfavorable prognosis in, 363 
diseases of, 348 
glioma of, 364 

a disease of childhood, 365 
clinical course of, 365, 366, 367 
diagnosis of, 364, 365 
malignancy of, 366 
symptoms of, 365, 366 
treatment of, 366, 367 
unfavorable prognosis in, 367 
pigmentary degeneration of, 354 
Retinal artery, embolism of, 357 
pulsation in, 279 
thrombosis of, 359 
Retinitis, 348 

albuminuric, 349 
etiology of, 349 
impairment of vision in, 349, 

350 
in pregnancy, 349. 35 l 
in scarlatina, 349, 351 
ophthalmoscopic picture of, 350 
pathology of, 350 
prognosis in, 351 
treatment of, 351 
uremic amblyopia in, 351 
diabetic, 351 

cataract in association with, 351 
fundus changes in, 351 
impairment of vision in, 352 
iritis and glaucoma in associa- 
tion with, 351 
prognosis in, 352 
treatment of, 352 
from exposure of the eyes to in- 
tense light, 353 
conjunctivitis in asso- 
ciation with, 354 

35 



Retinitis from exposure of the eyes 
to intense light, fundus 
changes in, 353 
how produced, 353 
prognosis in, 354 
symptoms of, 353 
treatment of, 354 
hemorrhagic. See Thrombosis of 

central retinal vein. 
leucocythemic, 352 

ophthalmoscopic picture of, 352 
pathology of, 352 
treatment of, 352 
of pernicious anemia, 352 
fundus changes in, 352 
prognosis in, 352 
treatment of, 352, 353 
parenchymatous, 348, 349 
pigmentosa, 354 

clinical historv of, 354, 355, 

356 
congenital anomalies frequently 

associated with, 354 
development of posterior polar 

cataract in, 356 
etiology of, 354 
in association with deaf-mutism, 

354 
night-blindness a characteristic 

symptom of, 355 
nystagmus not infrequently 

present in, 355 
ophthalmoscopic picture of, 

355 
pathology of, 355 
progressive contraction of visual 

field in, 355 
slow progress of, 354, 355 
symptoms of, 355 
treatment of, 356 
unfavorable prognosis in, 355 
primary, 349 
secondary, 349 
symptoms of, 348 
syphilitic, 353 

fundus changes in, 353 
prognosis in, 353 
treatment of, 353 
varieties of, 348 
Retino-choroiditis. See Choroido- 

retinitis. 
Retinoscopy, 422 
Retrobulbar neuritis, 374 
Rheumatic diathesis, 244, 389 
Rheumatism, 119, 242, 248, 268, 

291. 374 
"Ring ulcer" of cornea, 211 
"Ripeness" of cataract, determina- 
tion of, 307 



546 



INDEX. 



Risley, S. D., on the lessened preva- 
lence of high myopia in the United 
States, 406 

Roller-forceps, Knapp's. 1S1, 182 
in vernal conjunctivitis, 1S6 

Rontgen-ray apparatus. Sweet's. 500 

Rontgen-ray s in detection of foreign 
bodies in eyeball, 499, 500, 501, 
5°3 



Salicylate of sodium. See So- 
dium salicylate. 
Salicylates, the. in inflammatory con- 
ditions of eye. 59 
Salicylic acid, ointment of, 514 
in blepharitis. 66 
eczema of lids, 71 
vernal catarrh, 185 
Salt solution, subconjunctival in- 
jections of. in detachment of retina, 

3 6 3 - 3 6 4 
Sarcoma of choroid. 347, 348 

of ciliary body, 269 

of lacrimal gland, 125 

of lid and orbit, 80 

of orbit, 115 
Sattler's diplococcus. 174 
Schlemm's canal, 2S2 
Sclera and ciliary body, wounds of, 

494, 495 

diseases of, 242 
Scleritis, 242 

acute, 242 

chronic, 243 

diagnosis of, 243 

etiology of, 242 

symptoms of, 243 

treatment of, 243 

usually of rheumatic or gouty 
origin, 242 

varieties of, 242 
Sclero-conjunctivitis, 242 
Sclero-keratitis, 242 
Sclerosis of lens fibers, 295 
Sclerotitis. See Scleritis. 
Scopolamin, 48 
Scotoma, central, 353, 376 

color. 376 

paracentral, 374 
Scrofulous conjunctivitis. 186, 188. 
See also Conjunctivitis, phlyc- 
tenular. 

ophthalmia, 188. See also Con- 
junctivitis, phlyctenular. 
" Second sight " a premonitory symp- 
tom of cataract, 302, 306 
Secondary cataract. See Cataract, 

capsular. 



Seed-shells lodged on cornea, 488 
easily overlooked, 488 
peculiar behavior of, 488 
Senile, 2 7,6 

cataract, 298, 299, 300, 301, 302 
changes in crystalline lens, 295, 

296, 297 
decay, 302 
Senilis, a reus, 235 
Senility, 208 
Serous cyclitis. See Iritis, serous. 

iritis. See Iritis, serous. 
Serpent ulcer of cornea, 211 
Shadow test, 222 

Shortening lid, von Amnion's oper- 
ation for, 93 
Short-sightedness. See Myopia. 
SicheFs cataract knife, 145 
Silver foil as a dressing in lid oper- 
ations, 96 
as a surgical dressing, suggested 
by Halsted, 96 
nitrate in blepharitis marginalis, 
66, 515 
in purulent conjunctivitis, 164, 

168 
in severer types of conjunc- 
tivitis, 51 
in trachomatous conjunctivitis, 
180, 181 
Simple atrophy of optic nerve, 378 
glaucoma. See Glaucoma, simple. 
Simulated blindness, ^t> 
Sixth nerve, paralysis of. See 
Paralysis of external rectus muscle. 
Skiagraphy in detection of foreign 
bodies in eyeball, 499, 500, 501, 

5°3 
Skiascopy, 422 
Skin-grafting, 88, 94, 95, 96, 97 

silver-foil as dressing in, 96, 98 
Smith's, Nathan R., knife for divid- 
ing strictures of the nasal duct, 142 
Snellen's operation for spasmodic 
ectropion, 92 
test-types, 27 
Sodium chlorid, formula for collyr- 
ium of, 505 
subconjunctival injection of, 

23 8 . 337- 3 6 3> 3 6 4 

with bichiorid of mercury, 51, 
506 
pyrophosphate in cellulitis of orbit, 
no 

in dacryoadenitis, 120 

in dacryocystitis, 136 

value of, in suppurative proc- 
esses of the lids, lacrimal sac, 
and orbit, 62 



INDEX. 



547 



Sodium salicylate. 50, 518 
in choroiditis, 346 
in cyclitis, 269 

in episcleritis, 245 

in glaucoma, 2S9 

in iritis, 262, 263 

in optic neuritis, 373 

in periostitis of orbital walls, 

1 1 1 
in retrobulbar optic neuritis, 375 
in scleritis, 244 
in secondary glaucoma, 294 
in severe contusions of eye, 493 
in sympathetic ophthalmitis, 

^5 
in traumatic choroiditis, 346 
Solar retinitis, 353 
Somnolency induced by eye-strain, 

390, 41S 
Spasm of accommodation, 432 
of ciliary muscle, 432 
etiology of, 432 
from eserin, 432 
symptoms of, 432 
transient myopia produced 

b )'> 43 2 
treatment of, 433 
true refractive condition of 

eyes masked by, 432 
uncorrected astigmatism a 
common cause of, 432 
Spectacles, 429 

bifocal, 430 
Sphincter pupillae, paralysis of, 26, 

43 1 * 445> 
undue contraction of, 26, 379 
"Spongy" iritis, 259 
Spring catarrh. See Conjunctivitis, 

vernal. 
Squint, concomitant, 448 

alternating, 448, 451, 554 
amblyopia of misdirected eye 
in, 449 
how induced, 449, 450, 

45i 
not an example of "am- 
blyopia exanopsia," 

449 

origin of, not merely of 
theoretical interest, 45 1 
regional character of, 450 
significance of, 450 
characteristics of, 448 
consequences of, 449 
constant, 448 
convergent, 453 

etiology of, 396, 397, 453, 454 
Donders' dicta regarding, 
397, 453 



Squint, concomitant, convergent, 
hypermetropia most potent 
factor in causation of, 397 

in myopia, 454 

oftenest develops in early 
childhood, 453 

treatment of, 402, 403, 455, 456 
by glasses alone, 402, 455, 

45 6 
by operation, 455, 457, 458, 
45g, 460, 461, 462 
definition of, 448 
detection of, 452 

cover test in, 452 
divergent, 463 

development of, in mvopia, 

464 
etiology of, 407, 408, 463 
may develop at any time of 

life, 463, 464 
myopia most potent factor in 

causation of, 463, 464 
seldom alternating, 464 
treatment of, 464 

by glasses alone, 464, 465 
by operation, 465, 466 
etiology of, 438, 439, 448 
periodic, 448, 454 
primary, 452 
secondary, 451, 452 
varieties of, 448 
detection of, 452 
paralytic, 440 
diagnosis of, 441 
diplopia a characteristic symp- 
tom of, 441 
etiology of, 441, 442 
external rectus oftenest involved 

in, 442 
pathology of, 441, 442 
symptoms of, 441 
primary, 452 
secondary, 451, 452 
vertical, 466 
etiology of, 466 
glasses of little assistance in 

correction of, 466 
treatment of, 466 
Squints, 439 

characteristic features of, 439 
due solely to muscular faults, rare, 

439 
etiology of, 439 

of paralytic origin occur at any 
time of life, 439 
Staphylococcus aureus in keratitis, 
204, 210 
in phlyctenular conjunctivitis, 



548 



NDEX, 



Staphyloma, anterior. See Staphyl- 
oma oj cornea. 
of cornea, 161, 239 
anatomy of, 239 
etiology of, 239 
impairment of vision in, 239 
iridectomy for, 241 
Knapp's operation for, 241 
partial, 239 
total. 239 
treatment of, 240 
posterior, in myopia, 404, 406, 408 
Sterilization of collyria, 501 

of instruments by brief boiling, 
144 
Stilling, 142 
Stillson, 364 

Strabismus. See Squint. 
Streptococcus in suppurative kera- 
titis, 204, 211 
Stricture of canaliculus, 130 
of nasal duct, 137 

division of, practised by 
Nathan R. Smith, in 1846, 
142 
etiology of, 137, 138, 139 
location of, 139 
Nathan R. Smith's knife for 

dividing, 142 
often consequent upon nasal 

disease, 138 
often multiple, 139, 140 
transient, in new-born, 150 
treatment of, 140-150 

employment of large probes 
_ in, 143, 146 
varieties of, 140 
Strumous diathesis, 191 
Strychnin, 519 

in acquired ptosis, 100 
in diseases of the eye, 60 
in facial paralysis, 107 
in neuropathic keratitis, 222 
in paralysis of ciliary muscle, 432 
of sixth nerve, 443 
of third nerve, 446 
in primarv atrophv of optic nerve, 

381 
in quinin blindness, 378 
in retinitis pigmentosa, 356 
in retrobulbar optic neuritis, 375, 

377 
in secondary atrophy of optic 

nerve, 382 
preferably administered by the 
mouth, 60 
Stye. See Hordeolum. 
Subconjunctival hemorrhage, 193 
diagnosis of, 194 



Subconjunctival hemorrhage, etiol- 
ogy of, 194 
treatment of, 194 
injection of salt solution, 238, 337, 

363> 3 6 4 
Subnormal accommodative power, 

433 

a not infrequent cause of as- 
thenopia, 433 
asthenopia, how produced in, 

435 
described by author in 1891, 

433 
early development of pres- 
byopia a manifestation of, 

434 
how detected, 434, 435, 436 
may exist independently of 
other faults, or may com- 
plicate other errors, refrac- 
tive or muscular, 433 
of transient character, after 

use of cycloplegic, 435 
rule for correction of, 436 

for detection of, 435 
symptoms of, 433, 434, 435 
treatment of, 436, 437 

when complicated by re- 
fractive or other muscu- 
lar faults, 436 
satisfactory results of, 437 
underlying causes of, 433, 435 
"Sugar of lead," 237 
Sulphate of copper. See Copper 

sulphate. 
Sulphonal. 60 
Superficial lodgment of foreign 

bodies in eye, 486 
Superior oblique muscle, paralysis 
of. See Paralysis of superior 
oblique muscle. 
Suspensory ligament of lens, 295, 328 
Sweet's electro-magnet, 499, 503 
localizing chart, 502 
Rontgen-ray apparatus, 500 
Symblepharon, 480, 481, 482, 483 
Sympathectomy, 293 
Sympathetic iritis. See Iritis, sym- 
pathetic. 
irritation, 257 

prompt disappearance of, upon 

removal of exciting eye, 257 
symptoms of, 257 
ophthalmitis, 250, 256, 281, 493, 
497, 504. See also Iritis, 
sympathetic. 
etiology of, 256, 258, 259 
Sympathizing eye, 257, 258, 259 
Synchysis, 334 



NDEX. 



549 



Synechia, anterior, 37, 161,206,236, 

254. 293, 204. 404. 504 
posterior. 21, 26. 37, 247, 24c). 250, 

252. 254. 255. 258, 259, 260, 

207. 203. 294 
Syphilis a common cause of retinitis, 

340 
acquired ptosis oftenest due to, 98 
a factor in causation of lacrimal 

stricture, 139, 149 
cataract in inherited, 302 
characteristic physiognomy of in- 
herited, 227, 228 
commonest cause of iritis, 248, 255 
disease of deeper tunics of eye 

often dependent upon, 339 
facial paralysis from, 106 
importance of role played by, in 

etiology of diseases of the eye, 

57 
in acute retrobulbar neuritis, 374 
in choked disc, 372 
in dacryoadenitis, 119 
in descending optic neuritis, 372 
in hemianopsia, 385, 386 
in paralysis of ciliary muscle, 430 

of ocular muscles, 441 
in primary atrophy of optic nerve, 

379 

in retinitis, 353 

interstitial keratitis due to in- 
herited, 223 

iritis in inherited, 226, 255 

notched and pegged teeth in inher- 
ited, 227 

observations upon treatment of, 
58 

paralysis of third nerve oftenest 
due to, 444 

periostitis of orbit oftenest due to, 
in 

plastic choroiditis oftenest due to, 
340, 342 
cyclitis from, 268 

tarsitis from, 79 

tumors of orbit due to, 114, 115, 
117 

zonular cataract in inherited, 324 
Syphilitic choroiditis. See Choroid- 
itis, syphilitic. 

iritis. See Iritis, syphilitic. 

keratitis. See Keratitis, intersti- 
tial. 

retinitis, 353 



Tabes dorsalis. 378 
Tarsal cartilages, 85 
cyst See Chalazion. 



Tarsitis, 79 

treatment of, 80 

usually consequent upon acquired 
syphilis, 79 
Tattooing of cornea, 238 
Teeth, "dead," 222 
Hutchinson, 227 
Tenon's capsule, division of, in 
"free " tenotomies, 459 
non-division of, in "guarded" 
tenotomies, 477 
Tenotomies, graduated, little better 

than a pretence, 477 
Tenotomy, 455, 457, 458, 459, 460, 
461, 462, 465 
adrenalin helpful in operation of, 

461 
Arlt's method of performing, 457, 

465 
awkward methods of performing, 

formerly in vogue, 462 
best method of performing, 457 
description of operation of, 457 
early resort to, indicated in con- 
vergent squint, 462 
for correction of convergent squint, 

457 
how sinking of caruncle 
may be prevented in, 459 
why preferable to advance- 
ment, 457 
of divergent squint, 465 
of esophoria, 475, 476 
of exophoria, 472 
of hyperphoria, 478, 479 
had best be " guarded," 478 
indications for, 478 
little assistance afforded by 

glasses in, 478 
uncertainties which attend, 

47§> 479 
of latent muscular anomalies, 

47 I >47 6 ' 477 
of vertical squint, 466 
"guarded," 413, 477, 478 
how effect of, may be modified, 

459. 477 
in children. 461 
infection almost unheard of in 

operation of, 461 
instruments required in perform- 
ing, 458 
operation of, practically free from 
risk, 461 
Tension, intraocular, 23, 282 

increase of, collyria indicated 
in, 508, 509 
in glaucoma, 274, 276, 278, 
280, 282, 291 



550 



INDEX. 



Tension, intraocular, increase of, 
in glioma of retina, 365 
in intraocular growths, 363 
in serous iritis, 252, 261 
method of determining and 

noting, 23, 24 
subnormal, 282 

in detachment of retina, 363 
Theobald's lacrimal probes, 141. 

See also Author's. 
Therapeutic agents called for in the 
treatment of diseases of the eye, 

3.9 
Thiersch-grafts in correction of 
ectropion, 94, 97 
of entropion, 88 
silver-foil as covering for, 96 
Third nerve, paralysis of. See 

Paralysis 0} oculomotor ius. 
Thrombosis of central artery of 
retina, 359, 381 
etiology of, 359 
post-hemorrhagic blindness 

probably due to, 359 
symptoms of, 359 
treatment of, 359 
retinal vein, 359, 381 
consequences of, 359 
etiology of, 359 
ophthalmoscopic picture of, 

360 
treatment of, 360 
Tinnitus aurium from eye-strain, 

39° 
Tobacco a factor in causation of 

retrobulbar neuritis, 376 
Toxic amblyopia. See Optic neu- 
ritis, retrobulbar, chronic. 

conjunctivitis, 192 
Trachoma. See Conjunctivitis, tra- 
chomatous. 

usual cause of organic entropion, 
81 
Transient hemianopsia, 386 
Treatment of diseases of the eye, 

general observation upon, 38-62 
Trional, administration of, after 

operations upon the eye, 60 
"Trituration" of lens, 313 
Trochlear nerve, paralysis of. See 

Paralysis of superior oblique 

muscle. 
"Trophic nerve" keratitis. See 

Keratitis, neuropathic. 
Tuberculosis of lacrimal gland, 119 

of nose, 139 
Tuberculous periostitis of orbit, in 
Tumors of choroid, 348 

of ciliary body, 269 



Tumors of orbit, 113 

diagnosis of, 115 

etiology of, 113 

treatment of, 116 

varieties of, 114 
of retina, 364 
Turkish bath in iritis, 262, 266 
Typhoid fever, 208 



Ulcer of cornea, 207. See also 

Cornea, ulcer of. 
Uremic amblyopia, 351 
Urine, importance of testing, in 
optic neuritis, 373 
in retinitis, 350 
Uveitis, 252 



Vascular injection of eyeball, 
significance of different types of, 

35 
"Vaseline cerate," formula for, 46, 

5i3 
Velpeau's operation for removal of 

lacrimal gland, 124 
Venae vorticosae, 282 
Veratriae oleate, formula for, 515 

indications for, 515 
Vernal conjunctivitis, 183 
Vertical diplopia test of von Graefe, 
469 
squint, 466 
Vertigo, in ametropia, 390 
in astigmatism, 418 
in heterophoria, 467 
in paralytic squint, 439, 443 
Visual acuity, determination of, 2 7 
for near objects, 28 
when sight is greatlv impaired, 
28 
Vitreous humor, diseases of, 333 
fluidity of, 334 

consequences of, 334 

etiology of, 334 

oftenest met with in myopia, 

334 
hemorrhage into, 336 
absorption of, 337 
effect upon vision of, 337 
etiology of, 336 
ophthalmoscopic appearances 

of, 337 
origin of, 336 
serious consequences of, when 

recurrent, 337 
treatment of, 337 
opacities of, 334 
diagnosis of, 335 



INDEX. 



551 



Vitreous - humor, opacities of, disap- 
pearance oi, 335 
disturbance of vision from, 

335 

etiology of, 335, 336 
of little moment when micro- 
scopic, 335 
treatment of, 336 
varieties of, 335 



Warts upon lid margin, 78 

treatment of, 78 
Weber's canaliculus knife, 129 
Weeks' bacillus, 156 
Weeks on bacteriology of phlycten- 
ular conjunctivitis, 189 
Williams, E., and H. D. Noyes, first 

to use large lacrimal probes, 140 
Wolfe -grafts in operations for ectro- 
pion, 94 
Wounds. See also Injuries. 

of eye complicated by lodgment 
of foreign bodies 
within the ball, 

497 

cataract caused bv, 

498 
consequences of , 497, 

498, 499, 504 
danger of infection 

in, 497 
interesting cases of, 

49 8 > 5°3 

sympathetic oph- 
thalmitis from, 
497, 498, 504 

treatment of, 499 
antiseptic precau- 
tions in, 501 
electro-magnet in, 

499, 500, 503 
enucleation of eye 

not infrequently 
demanded in, 

5°4 
pain-reaction test 

in, 500 
skiagraphy in, 499, 

500, 501 

when foreign body 
is non-magnetic, 
502 
penetrating, 494 



Wounds of eye, penetrating, always 
of serious concern, 494, 

495 

antiseptic precautions de- 
manded in, 495, 496 

complicated by involvement 
of lens, 494 

consequences of, 494 

danger of infection occurring 
in, 494, 495 

enucleation of injured eye in, 

495. 497 
" first aid " in, 495, 496 
hernia of iris and ciliary body 

from, 494 
involving the choroid and 
retina, 495 

the cornea, iris, and lens, 

494, 497 
the sclera and ciliary body, 

494, 497 
sympathetic ophthalmitis 

from, 497 
traumatic cataract a not un- 
common result of, 495 
treatment of, 495, 496, 497 
of eyelids, 480 
Wyeth's elixir of phosphates of iron, 
quinin, and strychnin, 60 



Xerophthalmia, 176 
X-rays. See Rontgen-rays. 

Yellow oxid of mercury. See Mer- 
cury, yellow oxid. 

Zinc oxid and boracic acid, ointment 
of, 71 
formula for, 513 
sulphate, 50 

contraindicated in phlyctenular 

conjunctivitis, 189 
formula for collyrium of, 506 
in catarrhal conjunctivitis, 50, 

157 
in follicular conjunctivitis, 173 
in hordeolum, 69, 515 
in membranous conjunctivitis, 

169 
in vernal conjunctivitis, 185 
Zonular cataract, 324 
Zonule of Zinn, 295, 328 



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are of the greatest importance, not only because of their frequency, but also 
because of the difficulty of diagnosis and the special care demanded in their treat- 
ment. The text is elaborately illustrated with entirely new and original illustra- 
tions, neither labor nor expense having been spared to bring this feature of the 
work up to the highest standard of artistic and practical excellence. 



SAUNDERS" BOOKS OX 



Scvidder's 
Treatment of Fractures 

WITH NOTES ON DISLOCATIONS 

The Treatment of Fractures : with Notes on a few Common 
Dislocations. By Charles L. Scudder. M.D.. Surgeon to the Massa- 
chusetts General Hospital, Boston. Octavo volume of 562 pages, 

with 7 56 original illustrations. Polished Buckram. S5.00 net; Half 
Morocco, S6.00 net. 

JUST READY — NEW 5th> EDITION, ENLARGED 
FIVE LARGE EDITIONS IN LESS THAN FIVE YEARS 

Each year a new edition cf this remarkable work is called for, the new fifth 
edition having just been issued. Dr. Scudder has made numerous additions 
throughout the text, and has added some fifty new illustrations, greatly enhancing 
the value of the work. The articles on Dislocations, illustrated in that practical 
manner which has made Dr. Scudder' s work so useful, will be found extremely 
valuable. The text has been brought precisely down to date, containing the sur- 
geons' reports on the late wars and the important facts regarding fractures pro- 
duced by the small-caliber bullet. In the treatment the reader is not only told 
but is shown how to apply the apparatus, for as far as possible, all the details are 
illustrated. 



PERSONAL AND PRESS OPINIONS 

William T. Bull, M.D., 

Professor of Sur;r; . CV.'.V/v :f P ; r. :? 'dans and Surgeons^ Xew York City. 
" The work is a good one, and I shall certainly recommend it to students." 

Joseph D. Bryant, M.D., 

Professor of the Principles and Practice of Surgery y Ukzoersity and Beuemte H::pl*aX 
Med cal Collegf, X;z:: Y;rk Cit; . 
" As a practical demonstration of the topic it is excellent, and as an example of bookrr.aking it 
is nighly commendable." 

American Journa.1 of the MedicaJ Sciences 

" The work produces a favorable impression by the general manner in which the subject is 
treated. Its descriptions are concise and clear, and the treatment sound. The physical examination of 
the injured part is well described, and . . . the method of making these examinations is illus- 
trated bv a liberal use o: cuts 



SURGERY AND ANATOMY. 



Bickheun's 
Operative S\irgery 

RECENTLY ISSUED. 2d EDITION-TWO EDITIONS IN SIX MONTHS 

A Text-Book of Operative Surgery. Covering the Surgical Anat- 
omy and Operative Technic involved in the Operations of General 
Surgery. For Students and Practitioners. By Warren Stone 
Bickham, M.D., Assistant Instructor in Operative Surgery, Columbia 
University (College of Physicians and Surgeons), New York. Hand- 
some octavo of about iooo pages, with 559 beautiful illustrations, 
nearly all original. 

Cloth, $6.00 net ; Sheep or Half Morocco, $7.00 net. 

WITH 559 BEAVTIFUL ILLVSTRATIONS, NEARLY ALL ORIGINAL 

This absolutely new work completely covers the surgical anatomy and 
operative technic involved in the operations of general surgery. Constructed 
on thoroughly new lines, the discussion of the subject is remarkably systema- 
tized and arranged in a manner entirely original. Being the work of a teacher 
of extensive experience who, as such, is thoroughly familiar with the wants of 
students and general practitioners, the book is eminently practical and the sub- 
ject treated in such a manner as to render its comprehension most easy. This 
practicability of the work is particularly emphasized in the numerous magnifi- 
cent illustrations which form a useful and striking feature. There are some 559 
of them. All have been drawn especially for this book, and they depict the 
pathologic conditions and the progressive steps in the various operations 
detailed with unusual fidelity, their artistic and mechanical excellence being of 
the highest standard. The text has been brought precisely down to the present 
day, all the recent advances along the line of technic having been fully discussed, 
and elucidated with many illustrations. A distinguishing and extremely useful 
feature is the treatment of the anatomic side of the subject in connection with 
the operative technic. Anatomy of the human body is of the utmost impor- 
tance in the practical application of operative surgery, for unless the surgeon 
know the exact location of the various muscles, bones, etc., he will cause 
unnecessary destruction of tissue, and perhaps irreparable injury. The illustra- 
tions will be found of particular assistance in acquiring this essential knowledge. 

NICHOLAS SENN, M. D. 

Professor of Surgery, Rush Medical College, in Affiliation with the Univ. of Chicago. 
" A SOMEWHAT CAREFUL EXAMINATION OF THE TEXT AND ILLUSTRATIONS OF Dr. 

Bickham's book on Operative Surgery has satisfied me of its merits. The book 

WILL MEET WITH FAVOR ON THE PART OF TEACHERS, STUDENTS, AND PRACTITIONERS." 



SAUNDERS' BOOKS ON 



Moynihan's 
Abdominal Operations 



Abdominal Operations. By B. G. A. Moynihan, M. S. (Lond.), 
F.R.C.S., Senior Assistant Surgeon, Leeds General Infirmary, England 
Octavo, well illustrated. Cloth, $7.00 net; Half Morocco, $8.00 net, 

JUST ISSUED 

It has been said of Mr. Moynihan that in describing details of operations he 
is at his best. The appearance of this, his latest work, therefore, will be widely- 
welcomed by the medical profession, giving, as it does, in most clear and exact 
language, not only the actual modus operandi of the various abdominal operations, 
but also the preliminary technic of preparation and sterilization. Complications 
and sequelae and after-treatment are presented in the same clear, clean-cut manner 
as the operations themselves. The beautiful illustrations have been especially drawn. 

Edward Martin, M. D. 

Professor of Clinical Surgery, University of Pennsylvania 

" It is a wonderfully good book. He has achieved complete success in illustrating, both 
by words and pictures, the best technic of the abdominal operations now commonly performed." 



Moynihan on Gall-stones 



Gall=stones and Their Surgical Treatment. By B. G. A. Moyni- 
han, M. S. (Lond.), F.R.C.S., Senior Assistant Surgeon, Leeds General 
Infirmary, England. Octavo of 458 pages, fully illustrated. Cloth, 
$5.00 net. 

JUST ISSUED— NEW (2d) EDITION 

Mr. Moynihan, in revising his book, has made many additions to the text, so 
as to include the most recent advances. Especial attention has been given to a 
detailed description of the early symptoms in cholelithiasis, enabling a diagnosis 
to be made in the stage in which surgical treatment can be most safely adopted, 
Every phrase of gall-stone disease is dealt with, and is illustrated by a large 
number of clinical records. The account of the operative treatment of all the 
forms and complications of gall-stone disease is full and accurate. A number of 
the illustrations are in color. 

British Medical Journal 

" He expresses his views with admirable clearness, and he supports them by a large num- 
ber of clinical examples, which will be much prized by those who know the difficult problems 
and tasks which gall-stone surgery not infrequently presents." 



SI T RGER J ' AND ANA TOM\ 



Schuitze and Stewart's 
Topographic Anatomy 

Atlas and Text=Book of Topographic and Applied Anatomy. By 

Prof. Dr. 0. Schultze, of Wurzburg. Edited, with additions, by 
George D. Stewart, M.D., Professor of Anatomy and Clinical Sur- 
gery, University and Bellevue Hospital Medical College, N. Y. Large 
quarto of 189 pages, with 25 colored figures on 22 colored lithographic 
plates, and bg text-cuts, 60 in colors. Cloth, $5.50 net. 

JUST READY 

It was Professor Schultze' s special aim, in preparing this work, to produce a 
Text-Book and Atlas, not for the anatomist alone, but more particularly for the 
general practitioner. The value of the knowledge of topographic anatomy in bed- 
side diagnosis is emphasized throughout the book. The many colored lithographic 
plates are exceptionally excellent. 

Arthur Dean Bevan. M. D., Professor of Surgery in Rush Medical College, Chicago. 

" I regard Schultze and Stewart's Topographic and Applied Anatomy as a very admirable 
work, for students especially, and I find the plates and the text excellent." 



Sobotta and McMurrich's 
Human Anatomy 

Atlas and Text=Book of Human Anatomy. In Three Volumes. By 
J. Sobotta, M.D., of Wurzburg. Edited, with additions, by J. Playfair 
McMurrich, A. M., Ph. D., Professor of Anatomy, University of Mich- 
igan, Ann Arbor. Three large quartos, each containing about 250 
pages of text and over 300 illustrations, mostly in colors. 

JUST READY 

The great advantage of this over other similar works lies in the large number 
of magnificent lithographic plates which it contains, without question the best that 
have ever been produced in this field. They are accurate and beautiful reproduc- 
tions of the various anatomic parts represented. The clear but concise style of 
Professor Sobotta makes this work an ideal text-book for the student, and an inval- 
uable aid to the physician, surgeon, and anatomist. 



SAUNDERS' BOOKS ON 



Gould's Operations on the 
Intestines and Stomach 

The Technic of Operations upon the Intestines and Stomach. By 

Alfred H. Gould, M. D., of Boston, Massachusetts. Large octavo of 
300 pages, with 250 original illustrations. 

JUST ISSUED 

Dr. Gould's new work is the result of exhaustive experimentation, the technic 
of the operations described being simplified as far as possible by experiments on 
animals, thus leading to the development of many new features. The text is pur- 
posely concise, the technic being presented very clearly by the numerous practical 
illustrations, all made from actual operations done either upon the animal or the 
human being. As the success of gastro-intestinal surgery depends upon an accur- 
ate knowledge of the elementary steps, a thorough account of repair is included, 
followed by a full description of all the important stitches, knots, and instruments 
used in intestinal surgery. 



DaCosta's Modern Surgery 

Modern Surgery — General and Operative. By John Chalmers 
DaCosta, M. D., Professor of the Principles of Surgery and of Clinical 
Surgery in the Jefferson Medical College, Philadelphia. Octavo of 1 099 
pages, with 707 illustrations. Cloth, $5.00 net; Sheep or Half Morocco, 
$6.00 net. 

RECENTLY ISSUED— THE NEW (4th) EDITION 

In this new fourth edition the book has undergone a thorough and careful revis- 
ion, and there has been added much new matter and over two hundred excellent 
and practical illustrations. Because of the great amount of new matter, it has been 
deemed advisable in this present edition to adopt a larger type page. This is a 
great improvement, rendering as it does the work less cumbersome. 

The Medical Record, New York 

"The work throughout is notable for its conciseness. Redundance of language and pad- 
ding have been scrupulously avoided, while at the same time it contains a sufficient amount of 
information to fulfil the object aimed at by its author — namely, a text-book for the use of the 
student and the busy practitioner." 



SURGER Y AND ANA TOMY 



Itvterrvatiorval 
Text-Book of Surgery 

SECOND EDITION, THOROUGHLY REVISED AND ENLARGED 

The International Text=Book of Surgery. In two volumes. By 
American and British authors. Edited by J. Collins Warren, M.D., 
LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard Medical 
School ; and A. Pearce Gould, M.S., F.R.C.S., of London, England. — 
Vol. I. General and Operative Surgery. Royal octavo, 975 pages, 
461 illustrations, 9 full-page colored plates. — Vol. II. Special or 
Regional Surgery. Royal octavo, 1 122 pages, 499 illustrations, and 
8 full-page colored plates. 

Per volume : Cloth, $5.00 net ; Half Morocco, $6.00 net 

ADOPTED BY THE U. S. ARMY 

In this new edition the entire book has been carefully revised, and special effort 
has been made to bring the work down to the present day. The chapters on 
Military and Naval Surgery have been very carefully revised and extensively 
rewritten in the light of the knowledge gained during the recent wars. The 
articles on the effect upon the human body of the various kinds of bullets, and 
the results of surgery in the field are based on the latest reports of the sur- 
geons in the field. The chapter on Diseases of the Lymphatic System has been 
completely rewritten and brought up to date ; and of special interest is the 
chapter on the Spleen. 
The Medical Record, New York 

"The arrangement of subjects is excellent, and their treatment by the different authors is 
equally so. . . . The wo r k is up to date in a very remarkable degree, many of the latest opera- 
tions in the different regional parts of the body being given in full detail. There is not a 
chapter in the work from which the reader may not learn something new." 



Fowler's Operating Room 

The Operating Room and the Patient. By Russell S. Fowler, 

M. D., Surgeon to the German Hospital, Brooklyn, New York. Octavo 

of 172 pages, illustrated. Cloth, $2.00 net. 

JUST ISSUED 

Dr. Fowler has written his work for the surgeon, nurses assisting at an 
operation, internes, and all others whose duties bring them into the operating 
room. It contains explicit directions for the preparation of material, instruments 
needed, position of patient, etc., all beautifully illustrated. 



SAUNDERS' BOOKS ON 



American 
Text-Book of Surgery 

American Text=Book of Surgery. Edited by William W. Keen, 
M. D., LL. D., F. R. C. S. (Hon.), and J. William White, M. D., Ph. D. 
Octavo, 1363 pages, with 551 text-cuts and 39 colored and half-tone 
plates. Cloth, $7.00 net ; Sheep or Half Morocco, $8.00 net. 

FOURTH EDITION, REVISED AND ENLARGED— RECENTLY ISSUED 

Of the three former editions of this book there have been sold over 40,000 
copies. In this present edition every chapter has been extensively modified, and 
many of them have been partially, and some entirely, rewritten. Six entirely 
new chapters appear: Military Surgery, by Brigadier-General R. W. O'Reilly, 
Surgeon-General, U. S. Army, and Major W. C. Borden, Surgeon, U. S. Army ; 
Naval Surgery, by Admiral P. M. Rixey, Surgeon-General, U. S. Navy ; Tropical 
Surgery, by Captain Charles F. Kieffer, Assistant Surgeon, U. S. Army ; Examina- 
tion of the Blood, by Dr. Richard C. Cabot ; Immunity, by Dr. Arthur K. Stone ; 
and Surgery of the Pancreas, by Dr. Francis J. Shepherd. 

Edmund Owen, F.R.C.S. 

Member of the Board of Examiners of the Royal College of Surgeons, England. 
" Personally, I should not mind it being called The Text-Book (instead of A Text-Book) , 
for I know of no single volume which contains so readable and complete an account of the 
science and art of surgery as this does." 



Eisendrath's Clinical Anatomy 

A Text=Book of Clinical Anatomy. By Daniel N. Eisendrath, 
A. B., M. D., Adjunct Professor of Surgery and Clinical Surgery, College 
of Physicians and Surgeons, Chicago. Octavo of 5 15 pages, illustrated. 
Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 

RECENTLY ISSUED 

This new anatomy discusses the subject from the clinical standpoint. A por- 
tion of each chapter is devoted to the examination of the living through palpation 
and marking of surface outlines of landmarks, vessels, nerves, thoracic and 
abdominal viscera. The illustrations are from new and original drawings and 
photographs. 

Medical Record, New York 

" A special recommendation for the figures is that they are mostly original and were 
made for the purpose in view. The sections of joints and trunks are those of formalinized 
cadavers and are unimpeachable in accuracy." 



S17XGEK Y AND ANA TOMY I • 



GET A • THE NEW 

THE BEST A 1T\ ©TIC ©C rV STANDARD 

Illustrated Dictiorvoa*y 

NEW THIRD REVISED EDITION — 1500 NEW WORDS 

The American Illustrated Medical Dictionary. A New and 

Complete Dictionary of the terms used in Medicine, Surgery, Den- 
tistry, Pharmacy, Chemistry, and kindred branches. With tables of 
Arteries, Muscles, Nerves, Veins, etc.; of Bacilli, Bacteria, etc.; 
Eponymic Tables of Diseases, Operations, Stains, Tests, etc. By 
W. A. Newman Dorland, M.D. Large octavo, 798 pages. 

Flexible leather, $4.50 net ; with thumb index, $5.00 net. 

Howard A. Kelly, M.D.. 

Professor of Gynecology, Johns Hopkins University, Baltimore. 
" Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient size. 
No errors have been found in my use of it." 

Golebiewski and Bailey's 
Accident Diseases 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. 

Ed. Golebiewski, of Berlin. Edited, with additions, by Pearce 
Bailey, M.D. Consulting Neurologist to St. Luke's Hospital, New 
York City. With 71 colored figures on 40 plates, 143 text-cuts, and 
549 pages of text. Cloth, $4.00 net. In Saunders 1 Hand- Atlas Series, 

The Medical Record. New York • 

" This volume is upon an important and only recently systematized subject, which is 
growing in extent all the time. The pictorial part of the book is very satisfactory." 

HelfericK and Bloodgood's 
Fractures and Dislocations 

Atlas and Epitome of Traumatic Fractures and Dislocations. 

By Prof. Dr. H. Helferich, of Greifswald, Prussia. Edited, with 
additions, by Joseph C. Bloodgood, M.D., Associate in Surgery, 
Johns Hopkins University, Baltimore. From the Fifth Revised and 
Enlarged German Edition. 216 colored figures on 64 lithographic 
plates, 190 text-cuts, and 353 pages of text. 

Cloth, $3.00 net. In Saunders' Atlas Series. 

Medical News, New York 

" The author and editor have made a most successful effort to arrange the illustrations that the 
interpretation of what they are intended to present is exceedingly easy." 



12 SAUNDERS' BOOKS ON 

Svilt^rv aa^d Coley's 
Abdomirval Hernias 

Atlas and Epitome of Abdominal Hernias. By Pr. Dr. G. Sul- 
tan, of Gottingen. Edited, with additions, by Wm. B. Coley, M.D., 
Clinical Lecturer and Instructor in Surgery, Columbia University, New 
York. 119 illustrations, 36 in colors, and 277 pages of text. 

Cloth, $3.00 net. In Saunders' Hand- Atlas Serbs. 

Robert H. M. Dawbarn, M.D., 

Professor of Surgery and of Surgical Anatomy, Aew York Polyclinic. 

" I have spent several interesting hours over it to-day, and shall willingly recommend it to my 
classes at the Polyclinic College and elsewhere." 

Warren's Pathology and Therapeutics 

Surgical Pathology and Therapeutics. By J. Collins Warren, 
M.D., LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard Medi- 
cal School. Octavo, 873 pages; 136 illustrations, 33 in colors. 
With an Appendix on Surgical Diagnosis and Regional Bacteriology. 
Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net, 
SECOND EDITION, WITH AN APPENDIX 

Roswell Park, M.D., 

In the Harvard Graduate Magazine. 

" I think it is the most creditable book on surgical pathology, and the most beautiful medical 
illustration of the bookmakers' art that has ever been issued from the American press." 

Zuckerk&ndl and DaXost&'s 
Operative S\irgery 

ADOPTED BY THE U. S. ARMY 

Atlas and Epitome of Operative Surgery. By Dr. O. Zucker- 
kandl, of Vienna. Edited, with additions, by J. Chalmers DaCosta, 
M.D., Professor of the Principles of Surgery and Clinical Surgery, 
Jefferson Medical College, Phila. 40 colored plates, 278 text-cuts, 
and 410 pages of text. Cloth, $3.50 net. In Saunders' Atlas Series. 

SECOND EDITION, THOROVGHLY REVISED AND GREATLY ENLARGED 

New York Medical Journal. 

" We know of no other work upon the subject in which the illustrations are as numerous or as 
generally satisfactory." 



SURGERY AND ANATOMY 13 

Lewis* Anatomy and Physiology for Nurses Just issued 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M. D., Surgeon 
to and Lecturer on Anatomy and Physiology for Nurses at the Lewis Hospital, 
Bay City, Michigan. 121110, 317 pages, with 146 illustrations. Cloth, $1.75 net. 

A demand for such a work as this, treating the subjects from the nurse's point of view, 
has long existed. Dr. Lewis has based the plan and scope of this work on the methods em- 
ployed by him in teaching these branches, making the text unusually simple and clear. 
The object was so to deal with anatomy and physiology that the student might easily 
grasp the primary principles, at the same time laying a broad foundation for wider study. 



McClellan's Art Anatomy Recently issued 

Anatomy in Its Relation to Art. By George McClellan, M.D., Professor 
of Anatomy, Pennsylvania Academy of the Fine Arts. Quarto volume, 9 by 
12^2 inches, with 338 original drawings and photographs, and 260 pages of 
text. Dark blue vellum, $10.00 net ; Half Russia, $12.00 net. 

Howard Pyle, in the Philadelphia Medical Journal 

"The book is one of the best and the most thorough text-books of artistic anatomy which it has been 
the writer's fortune to fall upon, and, as a text-book, it ought to make its way into the field for which 
it is intended." 

Seilll OI1 TtimOrS Second Revised Edition 

Pathology and Surgical Treatment of Tumors. By Nicholas Senn, 
M.D., Ph.D., LL.D., Professor of Surgery, Rush Medical College, Chicago. 
Handsome octavo, 718 pages, with 478 engravings, including 12 full-page 
colored plates. Cloth, #5.00 net ; Sheep or Half Morocco, $6.00 net. 

Journal of the American Medical Association 

" The most exhaustive of any recent book in English on this subject. It is well illustrated and will 
doubtless remain as the principal monograph on the subject for some years." 

Senn Practical Surgery 5w&5£ 

Practical Surgery. A Work for the General Practitioner. By Nicholas 

Senn, M. D., Ph. D., LL. D., Professor of Surgery in Rush Medical College, 

Chicago. Octavo of 1 1 33 pages, with 650 illustrations, many in colors. 

Cloth, $6.00 ; Sheep or Half Morocco, $7.00 net. Sold by Subscription. 

"It is of value not only as presenting comprehensively the most advanced teachings of 
modern surgery in the subjects which it takes up, but also as a record of the matured opin- 
ions and practice of an accomplished and experienced surgeon.'' — Annals of Surgery. 

Macdonald's Diagnosis and Treatment 

A Clinical Text=Book of Surgical Diagnosis and Treatment. By J. W. 

Macdonald, M.D. Edin., F.R.C.S. (Edin.), Professor Emeritus of the Prac- 
tice of Surgery and of Clinical Surgery in Hamline University, Minneapolis. 
Octavo, 798 pages, illus. Cloth, $5.00 net ; Sheep or Half Mor., $6.00 net, 



H SAUNDERS* BOOKS ON 

Haynes' Anatomy 

A Manual of Anatomy. By Irving S. Haynes, M.D., Professor of Prac- 
tical Anatomy, Cornell University Medical College. Octavo, 6So pages, 
with 42 diagrams and 134 full-page half-tones. Cloth, I2.50 net. 

" This book is the work of a practical instructor — one who knows by experience the require- 
ments of the average student, and is able to meet these requirements in a very satisfactory 
way. - ' — The Medical Record, Xew York. 

American Pocket Dictionary rourth H:3Sf 

The American Pocket Medical Dictionary. Edited by W. A. Newman 

Dorland, A.M., M.D., Assistant Obstetrician, Hospital of the University of 
Pennsylvania, etc. 566 pages. Full leather, limp, with gold edges, $1.00 
net; with patent thumb index, $1.25 net. 

" I am struck at once with admiration at the compact size and attractive exterior. I can recom- 
mend it to our students without reserve." — James YV. Holland, M.D., Professor of Medical 
Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadelphia. 

Beck's Fractures 

Fractures. By Carl Beck, M.D., Professor of Surgery, New York Post- 
graduate Medical School and Hospital. With an Appendix on the Practical 
Use of the Rdntgen Rays. 335 pages, 170 illustrations. Cloth, $3.50 net. 

" The use of the rays with its technic is fully explained, and the practical points are brought out 
with a thoroughness that merits high praise."' — The Medical Record. Xew York. 

Barton and Wells* Medical Thesaurus Recently issued 

A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, 
M. D.. Assistant to Professor of Materia Medica and Therapeutics, and Lec- 
turer on Pharmacy, Georgetown University, Washington, D. C. ; and Walter 
A. Wells, M. D., Demonstrator of Laryngology, Georgetown University, 

Washington, D. C. i2mo of 534 pages. Flexible leather, S2.50 net ; with 
thumb index, $3.00 net. 

Stoney's Surgical Technic N^T^Edltion 

Bacteriology and Surgical Technic for Nurses. By Emily M. A. Stoney, 

Superintendent at the Carney Hospital, South Boston, Mass. Revised by 
Frederic R. Griffith, M. D., Surgeon, of New York. i2mo, 266 pages, 

illustrated. Si. 50 net 

" These subjects are treated most accurately and up to date, without the superfluous reading 
which is so often employed. . . . Nurses will find this book of the greatest value."— 
Trained ^'urse and Hospital Review. 

Grant on Face, Mouth, and Jaws 

A Text=Book of the Surgical Principles and Surgical Diseases of the 
Face, Mouth, and Jaws. For Dental Students. By H. Horace Grant, 
A.M., M.D., Professor of Surgery and of Clinical Surgery, Hospital College 
of Medicine. Octavo of 231 pages, with 68 illustrations. Cloth, $2.50 net. 

" The language of the book is simple and clear. . . . We recommend the work to those for 
whom it is intended." — Philadelphia Medical Journal. 



SURGER Y AND ANA TOMY 



15 



Warwick and TunstalKs First Aid 

First Aid to the Injured and Sick. By F. J. Warwick, B.A., M.B. 
Cantab., Associate of King's College, London ; and A. C. Tunstall, M.D., 
F.R.C.S. Edin., Surgeon-Captain Commanding the East London Volunteer 
Brigade Bearer Company. i6mo of 232 pages and nearly 200 illustrations. 

Cloth, $1.00 net. 

■ Contains a great deal of valuable information well and tersely expressed. It will prove 
especially useful to the volunteer first aid and hospital corps men of the National Guard."— 
Journal American Medical Association. 

Beck's Surgical Asepsis 

A Manual of Surgical Asepsis. By Carl Beck, M.D., Professor of Sur- 
gery, New York Post-graduate Medical School and Hospital. 306 pages ; 65 
text-illustrations and 12 full-page plates. Cloth, $1.25 net. 

m The book is well written. The data are clearly and concisely given. The facts are well 
arranged. It is well worth reading to the student, the physician in general practice, and the 
surgeon."— Boston Medical and Surgical Journal. 

Griffith's Hand-Book of Surgery Recently issued 

A Manual of Surgery. By Frederic R. Griffith, M. D., Surgeon to the 
Bellevue Dispensary, New York City. i2mo of 579 pages, with 417 illus- 
trations. Flexible leather, $2.00 net. 

" Well adapted to the needs of the student and to the busy practitioner for a hasty review of important 
points in surgery." — American Medicine. 

Serin's Syllabus of Surgery 

A Syllabus of Lectures on the Practice of Surgery. Arranged in con- 
formity with ' ' American Text-Book of Surgery. ' ' By Nicholas Senn, 
M.D., Ph.D., LL.D., Professor of Surgery, Rush Medical College, Chicago. 

Cloth, 1 1. 50 net. 

" The author has evidently spared no pains in making his Syllabus thoroughly comprehensive, 
and has added new matter and alluded to the most recent authors and operations. Full refer- 
ences are also given to all requisite details of surgical anatomy and pathology." — British Medi- 
cal Journal. 

Keen's Addresses and Other Papers just Ready 

Addresses and Other Papers. Delivered by William W. Keen, M. D., 
LL.D., F. R. C. S. (Hon.), Professor of the Principles of Surgery and of Clin- 
ical Surgery, Jefferson Medical College, Philadelphia. Octavo volume of 
441 pages, illustrated. Cloth, $3.75 net. 

Keen on the Surgery of Typhoid 

The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. 

Keen, M.D., LL.D., F.R.C.S. (Hon.), Professor of the Principles of Surgery 
and of Clinical Surgery, Jefferson Medical College, Philadelphia, etc. 
Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. 

" Every surgical incident which can occur during or after typhoid fever is amply discussed and 
fully illustrated by cases. . . . The book will be useful both to the surgeon and physician."— 
The Practitioner. London. 



16 SURGER Y AND ANA TOMY 

Moore's Orthopedic Surgery 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor 
of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. 
Octavo of 356 pages, handsomely illustrated. Cloth, $2.50 net. 

" The book is eminently practical. It is a safe guide in the understanding and treatment ot 
orthopedic cases. Should be owned by every surgeon and practitioner." — Annals of Surgery. 

Nancrede's Anatomy and Dissection, {[ditfoii 

Essentials of Anatomy and Manual of Practical Dissection. By 

Charles B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, 
University of Michigan, Ann Arbor. Post-octavo ; 500 pages, with full-page 
lithographic plates in colors, and nearly 200 illustrations. 

Extra Cloth (or Oilcloth for the dissecting-room), $2.00 net. 

" The plates are of more than ordinary excellence, and are of especial value to students in their 
work in the dissecting-room."— Journal of the American Medical Association. 

Nancrede's Principles of Surgery New U (2d) Edition 

Lectures on the Principles of Surgery. By Chas. B. Nancrede, M.D., 
LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan, 
Ann Arbor. Octavo, 407 pages, illustrated. Cloth, #2.50 net. 

" We can strongly recommend this book to all students and those who would see something 
of the scientific foundation upon which the art of surgery is built." — Quarterly Medical 'Journal, 
Sheffield, England. 

Nancrede's Essentials of Anatomy. %£&}££& 

Essentials of Anatomy, including the Anatomy of the Viscera. By Chas. 
B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University 
of Michigan, Ann Arbor. Crown octavo, 388 pages ; 180 cuts. With an 
Appendix containing over 60 illustrations of the osteology of the body. Based 
on Gray 's Anatomy : Cloth, $1.00 net. In Saunders Question Compends. 

" The questions have been wisely selected, and the answers accurately and concisely given." — 
University Medical Magazine. 

Martin's Essentials of Surgery. Seve R£,Sf tion 

Essentials of Surgery. Containing also Venereal Diseases, Surgical Land- 
marks, Minor and Operative Surgery, and a complete description, with illus- 
trations, of the Handkerchief and Roller Bandages. By Edward Martin, 
A.M., M.D., Professor of Clinical Surgery, University of Pennsylvania, etc. 
Crown octavo, 338 pages, illustrated. With an Appendix on Antiseptic Sur- 
gery, etc. Cloth, $1.00 net. In Saunders 1 Question Compends. 

44 Written to assist the student, it will be of undoubted value to the practitioner, containing as it 
does the essence of surgical work." — Boston Medical and Surgical Journal. 

Martin's Essentials of Minor Surgery, Band- 
aging, and Venereal Diseases. Sec °Edi« I ^ e „ vised 

Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By 

Edward Martin, A.M., M.D., Professor of Clinical Surgery, University of 
Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. 

Cloth, $1.00 net. In Saunders" Question Compends. 

44 The best condensation of the subjects of which it treats yet placed before the profession."— 
The Medical News, Philadelphia. 



AUG 14 1906 



